Thursday, February 21, 2008

Pay for Performance (P4P) & Disease Management

In keeping with the season, the Disease Management Blog wanted to bracket this week with a famous bit of verse from the 4th Chapter of Matthew:

The tempter came to him and said, "If you are the Son of God, tell these stones to become bread." Jesus answered, "It is written: 'Man does not live on bread alone, but on every word that comes from the mouth of God.”

At the time, most of the world was preoccupied getting enough to live on, not dying prematurely and securing as much power as possible. In dealing with these Three Great Temptations, this itinerant carpenter succinctly pointed out that mankind deserved better and that our greatest potential in every aspect of our day-to-day existence was built on something far greater.

Our effort to shape the delivery of health care is no different. I think the “bread alone” issue is what annoys many stakeholders about “pay for performance.” Patients wonder why physicians should be paid to “do the right thing,” while physicians distrust the use of pieces of silver to shape their profession. Both parties know "bread alone" falls short. As testimony to this, not too long ago I watched a respected colleague practically tear up a check at a Departmental meeting in disdainful disgust.

That’s why I was very interested in this telling videotape of Bob Margolis MD, the CEO of HealthCare Partners, discussing how P4P works in California. It’s about 40 minutes long and well worth watching. Kick back, get your lunch and enjoy.

It was not what you might expect. I thought Dr. Margolis was going to suggest that paying docs to do the right thing was bread enough. I was pleasantly surprised. Among his many excellent points is that paying docs to do the right this is all well and good, but more importantly:

  • This is also a function of not paying for the wrong thing.
  • The exercise in creating P4P generates measurement, which – independent of the bread - is a critical ingredient in the improvement of health care delivery.
  • P4P draws stakeholders to the table and gets everyone to talk about quality.
  • Because physician groups are large and many of the docs are salaried, they haven’t necessarily seen any increase in pay for their performance. Rather, the pay is used to invest in systems of care that promote performance. Important distinction.

The key lesson is that P4P may deliver more dollars to the doctors (since I'm a doc, the the disease management blog supports the idea), but when it's done right, it can be a catalyst that brings out other more important positive forces. I'm not necessarily saying this is a key to heaven, but there is something to be said for appealing to dimensions of health care that have nothing to do with self-interest.

As an aside, I’ll point out that the lessons are important for the disease management industry, which should also strive to live by more than bread alone. I’ll leave the broader dimensions of this to another blog, but at a more discreet level, check out McKesson’s AccessPlus P4P (more like Pay for Participation) for Medicaid in Pennsylvania (special attention to page 8). Just like the potential of a combined Medical Home-Disease Management approach, there may be merit to a combined P4P-Disease Management approach. McKesson deserves a lot of credit.

Or how about a P4P plus Medical Home plus Disease Management approach? Anyone know of any examples?

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