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?

we deserve it

But it's what pays by mortgage and feeds my kids. I'm not a rich doctor. I am on a fairly tight budget. After school loans, mortgage, car payments, groceries, gas, retirement etc. There isn't much left. I have to plan for my own retirement, nobody gives me a pension. Doctors have to live, too. I don't live in a big house, or buy expensive things.

I do the best job I can do for my patients, and when people can't afford it, I don't charge them at all. At the end of the day, I don't think it is unreasonable to ask to be paid for the job I do.

I'm sorry for your loss. Even though it doesn't apply to the topic at hand. G

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Some say I look like Buzz Lightyear....
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DISCLAIMER: I have no financial stake in ValueMD, or any medical school.

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

__________________
AUC Class of '99
Bored certified
I may be a jerk, but I'm a Jedi jerk like my father.

Some say I look like Buzz Lightyear....
(They're right)

DISCLAIMER: I have no financial stake in ValueMD, or any medical school.

Very true. Doctors like everyone else need to make a living. Even in places with socialized healthcare, people pay for it in the form of higher taxes or longer waiting times, both exist in Australia and much of Europe and Canada.

Shouldn't we all be doing our jobs? YES.

and be paid for what we do? Let me see........YEP.

So...what is the problem with being paid accordingly? I don't see the argument of folks who just want to complicate this further. Guys, girls life isn't fair, it hasn't been it won't be, that is nice for romantic movies. Our realities are in front of us, we face them, deal with them and move one. If you want to work for free, join the salvation army, become a missionary or go to Cuba, pardon my bluntness.

Max

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...."Beyond jealosy and betrayal; beyond hate and desire; beyond pain and death; lies the ultimate revelation; the final choice; the end; because the fate of destruction is also the joy of rebirth" Neon Genesis Evangelion

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.

__________________
AUC M.D. Class of 06'
OBGYN PGY-1.5

I hate Internal Medicine more than fascia

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.

Actually money is not a problem, 'No Money is a problem'........
...about death and birth, its not in our hands, except suicide and homicide.......

Nothing is certain in this world, neither marriage nor a carriage...peoplw who plan to spend a lifetime together, are separated in a moment...and people who you have never met, become friends for ages to come...

Let doctors make their money, let the patients be treated, let the world go on, for......there is a higher power which guns the machine of this world...let him do his/her job...just as we should keep doing our job...is there anything else we can do?....

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I am in a serious relationship....with med school.This semester I am sleeping with Physiology.......books