Saturday, March 24, 2007


Roy is working on a very nice post about the newest trend in medicine, Pay-For-Performance. We went to an excellent seminar about it this morning, so I'll let him do the honors of a formal recap. I just thought I'd put up some quick knee-jerk reactions to the whole thing.

The idea of pay-for-performance is that doctors will be monitored with regard to various yet-to-be-defined standards of health-care delivery and rewarded (or not) in response to adherence.

First of all, the thing that struck me was that everyone agreed that doctors needed to be measured but so far no one can agree on a ruler. Multiple governmental agencies, health care businesses and professional organizations have a finger in this pie but so far no one has pulled out a plum. There were obvious things discussed like requirements for proper physical assessment or laboratory monitoring, patient education, continuing education and the like but as each aspect was brought up there were parallel problems involved with the assessment. My favorite example: a proposal to make family involvement in patient care a benchmark. OK, sounds good. In prison? The family involvement we get there is the accidental kind, where they happen to meet in a holding cell. Another benchmark: proper referrals for psychotherapy (got any therapists handy over there in maximum security?).

But the main issue as I see it is that the physician becomes the sole endpoint of a very complicated healthcare delivery system. Adherence to practice guidelines could be a useful measure of healthcare quality, but what if the patient doesn't want to take those medicines? Or if you've already been through the guideline decision tree (meant, after all, for the easiest case scenarios which are never the ones I get)? There are just too many 'what-if' scenarios to really tailor one quality measurement system---an inpatient unit is different from a partial hospitalization program, which is different from an outpatient clinic which is different from an emergency room. And none of the guidelines or benchmarks even considered the possibility of a correctional environment.

Consider this: the state saves money by not providing resources to the health care provider. They set the benchmarks, then fine the health care company for failing to meet the benchmarks that they have not provided the resources to obtain. A financial win-win situation for the state. Now comes pay-for-performance, the dynamic now trickles down to the level of the individual clinician. The question that I asked the presenters---and which brought the room to a dead silence---was whether or not the P4P approach would lead to any requirement that publically-funded health care systems actually provide the resources to meet their benchmarks. If so, sign me up.

In the meantime, I can't wait for my final benchmark: the patient satisfaction and quality-of-life survey. Of course, in my situation that would be the quality-of-life-sentence survey.