Pay for Performance--Treating the Well and Avoiding the Sick.
On March 27th, a column in your paper appeared entitled “The one-word answer to health reform”. For the most part I agreed with the sentiments and ideas expressed in the op ed, however I thought it ironic that under the heading of “Lowering Bureaucratic barriers”, the authors unwittingly touted a government program which will erect significant and immediate barriers that will affect the sickest among us. Specifically they laud the idea that hospitals (and this will apply to individual physicians as well) will be paid for, as they put it, the “best care” not the “most care”.
This program sounds good, as all government schemes do initially. It is called P4P or Pay for Performance, and it seems reasonable that we should pay the better doctor and the better hospital more than we pay the bottom tier. BUT, and this is a big but--how is this determined? Government bureaucrats count what they can count, not what is ultimately important--very much like judging art by counting the brush strokes. In the case of P4P, for example, doctors whose diabetic patients are under good control will be paid a higher fee than those with worse average monthly blood sugars. The assumption is that the doctor totally controls the blood sugar. The truth is that patients may choose to drink and eat bon bons, they may be too poor to get their medicine in a timely fashion, or may simply have very brittle diabetes that is difficult to control by even the best of doctors. They may have learning deficits which make it difficult for them to be in perfect treatment compliance. What will happen to these people? They will be discharged from the doctors’ “panels” because doctors have to run their offices and pay their increasing overhead, and they cannot afford non-compliant patients who will lower their “grade” and therefore their revenues. Hospitals are already omitting the highest risk renal transplant candidates from the waiting lists because they will lower their “performance”. In short, the people who least need a doctor will have one, and the sickest among us will be out in the cold.
The other very bad aspect of P4P is its total lack of respect for the individual. In an age when we have sequenced the human genome, and could deliver medicine tailored to the individual patient, government is enforcing a one size fits all program. Under the rubric of “quality” we are forced into uniformity. People become statistical ciphers. As a surgeon, I am being told to treat patients by algorithms or face financial penalty, even when my individual patient may fall outside those guidelines. (So far I have been able to dodge an out and out confrontation, but the shootout at the medical OK Corral looms large).
Ultimately, when you take the king’s dime, you take the king’s rules. The only way to really give “Best Outcome to Every Patient Every Time” as written in the editorial, is to return the practice of medicine to patients and their doctors and hospitals. Government medicine, wherever it has been applied increases cost, decreases quality, reduces patients options, and ultimately results in patients dying needlessly. As Ronald Reagan said, “When government is the problem, more government is not the answer”. For more information on medical economics please check out AAPSonline.org
Lee D. Hieb, MD
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