Pay for Performance and Covert Rationing (2)

Posted on September 14, 2007
Filed Under General Rationing Issues, Primary Care in America |

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.

Consider, firstly, that the large insurers - and to some extent Medicare - have by now successfully dictated to primary care physicians that they can spend only 7.5 minutes (or perhaps 10 minutes if they’re lucky) per patient visit. This mandated brevity, indeed, is one of the chief complaints voiced today by both primary care doctors and their patients.

On the heels of this considerable success these same third-party payers now have launched P4P, which gives them the ability to dictate exactly how those doctors must spend their 7.5 minutes. If the doctors hope to avoid (at best) missing out on their 5% bonus or (more ominously) getting blackballed for delivering poor quality care, they’ll spend that allotted time doing whatever their P4P checklist says they must do.

Doctors can’t possibly do everything; P4P relieves them of the burden of having to decide which of the important patient care tasks they’ll do, and which will have to wait for a more propitious time, such as when the cows come home.

Now, DrRich will be the first to admit that most of the things on the P4P checklist seem potentially useful or at least benign. You can look at common P4P-approved tasks in a report from PriceWaterhouseCoopers, and see for yourself. How can anyone argue with cancer screening, cholesterol management, diabetes management, or the appropriate use of asthma drugs? These things are all good for patient care, aren’t they?

Sure they are. In fact, the designers of P4P programs have taken pains to make sure that the items they have put on on their checklists to date will not only reduce costs, but, whenever possible, will also be reasonably likely to improve patients’ health (or at least will be perceived that way). It’s one of the things that makes criticizing P4P so unrewarding.

But one would have to be very credulous indeed to believe, despite vociferous protestations declaring it to be so, that insurance companies and the feds are making a Manhattan Project out of P4P purely out of their passion for good outcomes. It is clear that reducing the cost of care is the chief driver of the P4P movement, and if it isn’t likely to reduce the cost of care, it isn’t going to make the P4P checklists.

Unfortunately, many patients need medical care that isn’t going to reduce the overall cost of care. Quite the contrary.

Take, for example, the 20% of Medicare patients who have at least 5 chronic medical conditions, and take at least 5 prescription drugs. Tending maximally to each of those medical conditions will likely cost a lot of money. Holding the office visit to 7.5 minutes, of course, goes a long way toward limiting the care that can be provided. But it still leaves the doctor with a disturbing degree of latitude. When deciding which of these problems to address during the brief office visit, the unfettered doctor might well choose a problem whose optimal management will greatly increase the cost of care. But happily, under P4P the decision of which problem to address is already made. The checklist reveals the appropriate choice.

For another example of optimal medical care greatly increasing the cost of care, consider the hundreds of thousands of heart attack survivors each year who are at increased risk for subsequent sudden death. Good clinical studies, supported by formal guidelines, recommend implantable defibrillators for many of these individuals. But implantable defibrillators, being extremely expensive, are mysteriously absent from anyone’s list of P4P clinical practice guidelines. (The sad fact is that preventing sudden death by any method, no matter how cheap - since it would prolong the life of patients who would otherwise continue consuming lots of healthcare due to their underlying heart disease - is diametrically opposed to the real purpose of P4P. Under a system of covert rationing, preventing sudden death is simply bad public policy.)

But P4P not only limits the options of the doctor. It also limits the options of the patient. While patients have the right to turn down therapy that is recommended by P4P guidelines (and that is duly parroted to them by their higher-quality physicians), they are unlikely to be offered alternative choices not sanctioned by the guidelines, unless that alternative therapy is cheaper, or their doctors are willing to defy the insurance companies or (even less likely) the heavy hand of the feds.

Finally, since succeeding with many of the P4P measures requires not only that the doctor treat the patient appropriately, but also that the patient become fully compliant with the treatment recommendations (carefully following, for instance, their diabetic regimens), P4P may cause doctors to avoid accepting into their practices patients who seem unlikely to follow their instructions. Such patients will tend to include the poor, the disadvantaged, and the undereducated. But then, in all fairness to P4P there’s really nothing new here; these individuals are already the most likely victims of covert healthcare rationing.

So P4P offers many advantages to a healthcare system predicated on covert rationing.

No wonder everyone is on the P4P bandwagon.

Comments

2 Responses to “Pay for Performance and Covert Rationing (2)”

  1. The Covert Rationing Blog » Blog Archive » The AMA Takes on In-Store Health Clinics on September 21st, 2007 7:51 am

    [...] the entities that are paying the bills; doctors have relatively little to say about it. Further, as we have seen, with the introduction of P4P even the content of these brief visits is increasingly scripted by [...]

  2. The Covert Rationing Blog » Blog Archive » Why Implantable Defibrillators Have To Be Rationed on November 7th, 2007 9:33 am

    [...] and in his writings on this space DrRich has not been shy about pointing that out, for instance, here, here and here. DrRich believes that covertly rationing the ICD, like all covert rationing, is [...]

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