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.


NeoNurseChic said...

It sounds like the tick-boxes in the NHS, and that's just scary. As not everyone fits into strict diagnostic criteria for a certain illness, not everyone will fit into a strict protocol for what is supposed to be done. There are so many exceptions - and the exceptions are what neeed the most care, the most help, the most medical attention - as they are the difficult cases - the ones that are hard to fix. But maybe that's just me...

Looking forward to seeing Roy's post, too!

Take care,
Carrie :)

NeoNurseChic said...

OT but I'm not sure if all of you can read my blog, or just Dinah can. At any rate - let me know and I will try to fix it so that all of you can see it. I have recorded some new music - really I re-recorded 3 songs: "I Can't Make You Love Me", "Memory" and "I Know The Truth" and then just recorded one new song, "There You'll Be". Just thought you might be interested! Let me know about the blog... Take care!

Carrie :)

Catherine said...

Reminds me of what my state wants to do for teachers (but hasn't yet, thank goodness). Like you mentioned in the post, there is inpatient vs outpatient vs partial hospital - all of which have specialized needs that are tailored to the services they provide. How is possible to have a gold standard for everyone when, like neonursechic said, "There are so many exceptions"? It's not possible. If everyone had the exact same type of patients, cookie-cutter patients, then it might be feasible. But they don't.

Midwife with a Knife said...

Benchmarks are tough. You can't judge outcomes, because your outcomes are highly dependant on the risk of your population. Then, you have to look at the evidence for things associated with good care. Evidence is very tricky, and often doesn't exist for things that we "know" work. Various studies have various flaws and may or may not be applicable to the patient population you're taking care of; not only that, there's a great deal of variability within populations. Its reminiscent of when insurance companies were trying to make obstetricians try to make every woman with 1 previous c-section VBAC, whether or not they were really good candidates.

ClinkShrink said...

Yes Catherine it is very similar to teaching I think; during this seminar I kept thinking of No Child Left Behind and some of the discussions I've had with a friend of mine who is a school reform advocate. Even if the *only* thing you are looking at is outcome, the number of confounding variables are enormous. And there is no guarantee that your benchmarks actually are associated with "quality" care or good outcome.

Nevertheless, this is where we are headed. The thing that I thought was fascinating was that even in free society, with insurance, the majority of patients aren't getting care associated with benchmark standards. The presenter showed data that even with insurance, 25% of inpatients are not getting a followup appointment within 30 days after discharge. For medicare and medicaid recipients it was even worse---something like 10% got seen within 30 days. And this included followup by a non-mental health professional (eg. primary care doc).

The other thing that struck me was that our correctional contract had standards that are higher than what some of the P4P folks are proposing. Interesting considering that we have higher volume, sicker patients and fewer resources than the clinicians they are targeting out there in free society.

Sarebear said...

Oy, that's just sad.

My state has rebelled and opted out of the No Child Left Behind thing, which means less to little to no federal funding of a variety of kinds, but . . . it's too rigid.

Plus, with Utah's 50% Mormon population, there are rather more kids per household or whatever than many places . . . also the tiny farming towns and other such, and way spread out small towns . . . No Child Left Behind just doesn't fly well, here.

Not what the post is about, but yeah it goes to show how the one size fits all approach just sucks.

ClinkShrink said...

That's not much of a loss Sarebear; I did a little googling and it looks like the Feds fund only about $600 of the $6300 per student per year that goes into public education there. Hardly enough of an incentive to comply with NCLB. I'm surprised more states don't opt out.

Thanks for the pic Dinah. I'm getting lazy---I took it for granted you'd find a good one.

Anonymous said...

Maybe we should have pay 4 performance for customer service reps at insurance companies. If they provide crappy service (or deny/drag their feet processing claims), I send them less $$ each month? What do you think?

ClinkShrink said...

I like that. Hmm...let's for performance politicians?

Naw...we've already got that here in MD.

Sarebear said...

Actually, if you knew how much that $600 per child per year would go . . . . . heck just $600 more per year per class, would let em buy some good stuff for one classroom, say my daughter's. Or let them actually go on field trips that you don't have to do a zillion bake sales or whatnot to raise the funds for.

Let's see, 30 kids per class (it's close to that, here, which is ridiculous) timex $600 - that's $18,000, isn't it?

The school has to beg and plead for monies to help them in many areas, but especially for more licenses for a math program on the computers, which I think might be recommended or mandated by the state, but certainly not funded (arg). They only have enough licenses so only 6-8 kids in the school can be using the program at once.

That's just STUPID. Each license is $1500 (ouch).

Anyway, it's alot of money, in a state where since there's more kids per household than other places, that makes the taxes higher to educate each child (we had a huge state surplus this year, I hope they sent alot of it to education but I don't think they did, idiots. Mental health too.) They are having to beg teachers to come out of retirement or put it off, cause they have trouble getting new teachers (gee, at the paltry rate they pay I wonder why?)

Anyway! The teachers and educators still supported leaving NCLB tho, because it was a PITA, with some stupid measures in it.

Sorry to go on so long! I'm pleased that you googled it though, and took an interest in it!

DrivingMissMolly said...


I'm with Carrie on the sounding like the "tick-boxes in the NHS."

I know that I don't want a bit of my very expensive Shrink appointment to be wasted with stupid questions or irrelevant questions.

I don't understand how any reasonable person can think that it is possible to rate the performace of a professional on an outcome they are not 100% in control of.

I see a Shrink and he has prescribed for me three meds. If I don't get better because I didn't take them, how is he responsible for that? Even if I DO take them and don't get better (what does "better" mean when you are talking about a psych PT anyway?)that's not necessarily Shrink's fault, no matter how much I want to blame him.

I've been feeling so much better for about three weeks. What's different? I have no idea. Why should he get the credit?

Anyway, I can't believe the AMA, who has such a powerful lobby, isn't going to get this little initiative killed. This is just what we DON'T need, non-medically trained beaurocrats poking their heads in doctors' business.