Pay for Performance and Covert Rationing (1)
Posted on September 11, 2007
Filed Under Gekkonian Rationing, General Rationing Issues, Primary Care in America, Wonkonian Rationing |
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Pay for Performance (P4P) is the latest trend among health insurers and our friends in the government in their never-ending efforts to assure that patients in their charge are receiving top-quality healthcare. At least, that’s what they say.
Under P4P, certain “clinical practice guidelines” are developed by Medicare or private insurers, based on the principles of evidence-based medicine, to establish uniform standards of care for certain medical conditions. Then, doctors who meet specific “performance indicators” based on those guidelines will receive some sort of financial award at the end of the year. (The most common reward is a 5% bonus.)
Given the stated aims of P4P (quality improvement), and the fact that it is asserted to be grounded in state-of-the art medical science and mathematics, it immediately becomes inadvisable to criticize the effort, lest one be instantly revealed as a medical heathen.
DrRich will take the risk.
For, while P4P might be a reasonable tool for improving outcomes under some circumstances, under a healthcare system that fundamentally traffics in covert rationing (that is, where withholding healthcare covertly has become the prime directive), P4P is destined to be twisted to that end. P4P is an especially insidious tool for covert rationing precisely because it seems so reasonable and scientific on its face.
While P4P has been touted as a revolutionary new approach to quality healthcare, it is actually a repackaging of techniques traditionally used in managed care for many years. It is perhaps most similar to the “clinical pathway” initiatives that were common in the 1990s. The major difference, in fact, between clinical pathways and P4P is that the former were devised, implemented, monitored, and continuously adjusted locally, under the direct control of the doctors and administrators on the scene; whereas the latter are handed down from On High (either from Castle UnitedHealth Group, or from the Great City of Oz itself), and are not amenable to the continuous, data-driven process improvements that are the real hallmark of classic managed care. Far more than clinical pathways ever did, P4P threatens to become a matter of making ticks on a centrally-dictated check list.
P4P also relies on the Axiom of Industry - that the standardization of any process both improves quality and reduces cost. As DrRich has described elsewhere, the Axiom of Industry does not hold when the process involves actual human patients. This is because patients are not widgets. (While everyone agrees that patients are not widgets, the implication of this fact seems to have escaped many: What happens to the individual widget on an assembly line is immaterial - discarding even a high percentage of proto-widgets may be fine - as long as the ones that come out the other end are of sufficiently high quality as to yield the optimal price point in the market. Patients not being widgets, in theory we are supposed to care about what happens to the individual patient during the process.) Nonetheless, invoking the Axiom of Industry - equating reduced cost to improved quality - allows the central authorities to choose “quality measures” in their P4P efforts that will primarily reduce cost, and then to claim that their primary concern is for quality.
Those who have implemented P4P programs have been careful not to measure the results of their efforts based on patients’ actual clinical outcomes, but instead they determine the success of their programs based on the compliance of physicians with the received “practice guidelines.” Pay for performance is really pay for compliance. Compliance with guidelines received from on high BECOMES the outcome, the outcome that determines whether patients are receiving quality care.
But as any objective observer can tell you, care guidelines themselves are inherently problematic. (DB’s Medical Rants has an enlightening series of posts describing how this is so.) The scientific evidence used to establish guidelines is most often incomplete, is based on “idealized” and carefully chosen patients who rarely represent the actual patients seen by doctors in the wild, and is often inconsistent or contradictory. Such evidence can be applied to real patients only after careful consideration and interpretation, and making decisions based on such evidence requires a combination of clinical judgment and educated guesswork, even given a set of official guidelines. Whose judgment and guesswork ought best to be brought to bear - the clinician on the scene, or some remote bureaucrat? DrRich understands that the answer to this question is not straightforward for everyone, but he suspects most people would choose for their doctors to do it. In any case, the conceit voiced by proponents of P4P - that the right medical decision in most clinical situations can be predetermined objectively, and at a distance no less - is simply wrong.
But compliance is compliance, and doctors who do not comply with centrally-dictated guidelines will have a greater price to pay than merely missing their 5% bonus. Aetna, UnitedHealth Group and Cigna are already being scrutinized by the New York Attorney General for possibly steering patients away from less compliant (read: more expensive) doctors, on the purported grounds of their less-than-optimal quality of care.
These problems with P4P are at least reasonably straightforward and easy to spot. In his next post, DrRich will address some more insidious - and potentially more dangerous - aspects of P4P.
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P4P and Covert rationing…
DrRICH’s posting on P4P is a masterpiece and it is only Part One….
[...] look forward to reading Dr Rich’s book. This rant (Pay for Performance and Covert Rationing) expresses many thoughts that I have previously expressed concerning P4P. I especially like this [...]
Those who have implemented P4P programs have been careful not to measure the results of their efforts based on patients’ actual clinical outcomes, but instead they determine the success of their programs based on the compliance of physicians with the received “practice guidelines.”
If true, there is a phrase for this:
Scientific fraud.
Two comments about this interesting post by DrRich.
I support DrRich’s statement that P4P lacks “data-driven process improvements.” A recent study (http://archsurg.ama-assn.org/cgi/content/full/141/4/353) showed that the Universal Protocol would have been unable to prevent a significant percentage wrong site surgery errors. What is needed is a closed loop process of a quality goal, measurements, and process improvements until the goals is reached. In the reliability world, FRACAS (Failure Reporting And Corrective Action System) is such a closed loop process.
However, I take issue with the comparison between widgets and patients. It is implied that widgets are simple and patients are complex. My field of in-vitro diagnostic assay systems involves what could be called “widgets” but they are highly complex widgets! In that sense they rival patients, because one cannot predict how these systems will fail – knowledge is insufficient and therefore quality improvement is achieved through empirical, data-driven methods. Anesthesiology is an example of medical error quality improvement using data driven methods and long before the current focus on medical errors. See: http://qshc.bmj.com/content/vol11/issue3/#CLASSIC_PAPERS
The point is not that widgets are simple and patients are complex. It’s that a widget can be tossed in the recycling bin if it doesn’t meet specs. Try doing that with your non-compliant patients and you’ll be taking over Dr Kevorkian’s cell!
[...] In a previous post, DrRich described the most obvious problems with Pay for Performance (P4P) when applied under a system of covert rationing. In the present post he addresses some of the more subtle and insidious aspects of P4P. [...]
Regarding your comments on standardization of processes and “patients are not widgets”; this does not mean that standardization of all processes in hospitals is bad. For instance, the process of ordering, receiving, and transfusing blood to the proper patient should be rigidly standardized to avoid error. Similarly, the process of maintaining proper patient identification at all times during the hospitalization should be rigidly standardized . Although I agree with you that such standards cannot always be applied to an individual physician’s process of diagnosis and treatment of the individual patient, do not throw the baby out with the bathwater. Standardization of process in hospitals will do much to reduce medical errors.
[...] are the mandate that primary care doctors spend only 7.5 minutes per patient encounter; invoking the magic of P4P to script for those doctors exactly what must and must not take place during that 7.5 minutes; [...]