Quote:
Originally Posted by BrendaB_MD
So what do you guys propose? I think it is important to distinguish between the general principle of P4P and the methods by which it is implemented. On a philosophical level:
Should doctors be evaluated?
Should doctors' rewards be linked to their performance?
If so, what methods should be used to evaluate performance (e.g. process based or outcome based)?
How should physicians performance be rewarded? Should it be strictly informational or financial. Should performance metrics be made public?
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On the surface, it seems simple. Set some benchmarks and see if docs meet them. There are a lot of variables. I touched on diabetes before. Would a doc in an area where people are less educated have the same success with patient education/compliance as a doc in an area where his patient base is well educated? doubt it.
Performance also depends on your patients. I get these letters from Aetna (insurance company):
Patient "Y" has diabetes. You have not done the following:
- Urine microalbumin in the past year
- Hemoglobin A1C in the past 6 months
- There are no claims for an ACE inhibitor or and ARB
- There are no claims for a statin
Please consider doing these.
So, I pull the chart. I see the guy every 6 months, even though I tell him to follow-up every three. He hasn't had labs done in 3 years (even though I have documented that I discussed the importance of doing them regularly at the last 6 visits). He is on a statin and an ARB, I have documented that I gave him his prescriptions. I'm doing everything I should. He isn't. Under pay for performance, this guy is getting dropped like a hot potato. He is the person that needs a doc the most. Multiple risk factors for morbidity and mortality, need for continued education etc. He will get fired from a lot of practices and nobody will want to see him. He will mess up people's curves. It will be like picking teams for kickball in grade school. Nobody will want the kid that sucks.
Why should a doctor be "rewarded"? Shouldn't we all be doing our jobs, and be paid for what we do? Maybe come up with some system to find the docs that AREN'T doing such a good job. The ones that don't follow any of the accepted guidelines, or who have a high mortality/infection rate etc. I do not agree with extra incentive for doing a "good job". We should all be striving to do the best job we can for our patients. This will hurt it.
Performance metrics, even if you can come up with good ones, should not be made public. There are too many variables. The public won't understand. One of my partners is one of the best internists who ever walked the planet, IMHO. This guy got 6 wrong on his medicine boards. He is a great patient advocate, he is a superb clinician. He has a sicker patient population than post. As a result, the rate of hospitalization among his patients is higher than that among mine. He has more people die per year than I do. If you publish that without background, then he looks like he sucks. I doubt any government program would look that far into it. G