A couple of clarifications. Personally, I don't think there is anything wrong with doctors charging what the market will bear. I also don't think it is wrong for consumers of medical services (insurance companies, patients, etc) to get the most for their money. There is no fairness here -- just simple dog eat dog economics. It seems to me that its the doctors here who are making an appeal to fairness because they believe that review systems or P4P would be 'fair'.
To AUCMD2006:
I think you will find that the research literature on M&Ms suggests that they are a fairly ineffective method of quality improvement.
I agree that making information public has its problems but it also has potential benefits. For example, NY state changed accreditation of hospitals for CABG after adverse event rates were made public. If I recall, correctly, they cut the mortality rate 40% in ONE year by closing hospitals that performed less than 50 a year. (A researcher would win a Nobel Prize for an intervention that had that kind of impact). I doubt that this would have happened if the information had not been made public. In general, information is a good thing.
Also, the error rates in medicine are unacceptably high. Medicine lags other fields in the implementation of quality improvement systems. Truly, reading the quality improvement literature in medicine is like traveling back in time to the early 1990s because medicine is discovering all the stuff that has been routine in other industries. The point is that medicine's home grown approaches (M&M, event review, etc) have not performed well and, as a result, medicine lags other areas in quality improvement. I will be the first to admit that medicine is more complex and has unique features -- but so do lots of other industries. The point is that medicine can only improve if process measurements are put in place.
Also, a lot of the review systems are designed to deal with big screw ups. These are the tip of the iceberg that is visible. The biggest part of the iceberg are small decisions of suboptimal care that cost money and increase morbidity and mortality. Each decision is small but in aggregate they respresent a serious problem. Study after study show huge variation in practice and that a substantial fraction of doctors follow suboptimal practice. It seems to me that it is reasonable to audit process based measures (e.g. the extent to which physicians adhere to evidence-based guidelines) to provide feedback to doctors who provide suboptimal treatment.
I agree that physicians cannot control their patients adherence; however, physicians can control their own actions. Thus, process based measures are more appropriate than outcome based measures. Still, outcome measures can be used as a flag to identify potential underperformers.
As you state, many P4P systems are in place. I think the question is now one of tactics rather than strategy.
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Originally Posted by AUCMD2006
should doctors be evaulated?
yes we should and we are. the hospital keeps track of my admissions, re-admissions, infection rate, mortality rate. we have peer review, adverse outcome review, sentinel event review. the state monitors rx writing, the insurance companies monitor the referrals and utilization. we have to be board certified then keep getting re-certified.
i don't know what else you want other than going public with the data which as teratos already pointed out will be a very very very bad idea because non medical people do nolt understand the variables. when, not if, i have a bad outcome and i think i could have done something better it goes to peer review and morbidity and mortality conferrence whose records are sealed..i have no problem standing infront of fellow obs/surgeons and tearing down a case but if a patient hears about the 10 different ways the procedure could have been done differently then it will seem like i was negligent when in fact none including the original one may have had a better outcome.
so we have these per reviews and m&m's to learn from experience and that is what really counts in this..the more i see the more i learn that our medical books barely cover the surface of what we need to do and the system in place now is continuing to evolve. we sit in monthly m&m's and been onvolved in one peer review of a case and going through it is rough but it is amazing to sit in a room of my peers and superiors and be grilled, questioned and get view points on how to handle things this way or that way..basically be in a room with 300plus years of practice experience and while rough it is rewarding to learn from it, and at the end be aqpprocahed and told that something similar happened or hear about some of their bad outcomes and if a public system is implemented all that wealth of experience and candor would likely vanish
are our "rewards" linked to performance?
they already are, if you have hmo contracts and follow formulary, if your referral rate is low or at least within nomrla range of your peers in your area then you get quarterly bonuses.
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