Sunday, April 6, 2008

The Disease Management Care Blog Speaks About Pay for Performance (P4P)

Readers of the Disease Management Care Blog may recall the scrolling 'Check It Out' 'ABQAURP' icon that was posted on the right. It’s been taken down because the April 5 Chicago conference is over. Listening to the other speakers was a wonderful learning experience and I hope to be sharing some of their insights later on this week.

It was my privilege to talk on the topics of physician measurement and pay for performance (P4P). In no particular order, here is a bulleted summary of some of the points I made.

  • Lay-consumers have trouble understanding why physicians need to be paid to do the right thing.
  • An underlying value proposition for P4P and quality is that it mostly decreases costs. Unfortunately, that remains an unproven assumption in many domains of chronic care and wellness.
  • While the ‘pay’ in P4P from a payor perspective amounts to millions of dollars, for the physicians it typically results in hundreds of dollars. Most physicians I talk to feel that is not enough.
  • Yet, while P4P has the potential to get real dollars to the physicians, its real value is that it prompts physician engagement, a measurement culture and the creation of ‘systems’ of care.
  • The same measurement processes that support P4P are inevitably used to array physicians by cost and quality, which inevitably leads to restricted networks. That means winners and losers and, apparently, the involvement of State Attorney Generals.
  • Much of the scientific literature indicates most of today’s versions of the electronic health record do not necessarily save money or improve quality. It is clear is that they disrupt workflow, enable upcoding and may facilitate gaming. Their presence alone is not necessarily performance and does not warrant payment.
  • If we are going to base P4P on short term process or intermediary outcomes, ACCORD (A1c) ENHANCE (LDL) and Rosiglitazone (A1c) teach us that we better be sure about that those measures tell us what we think they tell us.
  • P4P may be necessary, but is not sufficient, to promote physician behavior change.

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