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![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Not limited to California
It all depends on the context
Its the process
Perception as reality
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Phillip S. Budzenski, MD, Carmel, IN, USA Physician
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My experience in a P4P situation utilizing an EHR was similar to those physicians in California. The EHR was fraught with inefficiencies. It was not set up for the medical assistants or nurses to get the non-visit-related documentation out of the way and entered into the system, (screening studies, vaccines, flu-shots, etc.) and did not allow for the medical assistants or nurses to add ROS information (as they would usually perform in a paper-based system). Separate from any performance/ non-performance indicators for the 3rd party payors, the system slowed down the whole process, preventing efficiency. The only first- hand feedback I obtained from the third-party payors was based on prescription information that they obtained through the drug stores/ dispensers, not the EHR. Non-compliance with routine screening was documented when the patient was seen for a URI, "missed" flu shot when they were seen in the early summer. The frustration was beyond belief. The idea that someone actually purchased the system against the recommendation of their evaluating physician - even more so. When the slowness/ inefficiency of the system was shown to my practice manager, and the "issue" (complaint) was taken to the higher management, my practice manager was fired. My contract was up a few months later and I chose to not enter into a new contract. I have since been told that the EHR in question was dumped in the next year or two. (Unfortunately the company may still be in business.) Competing interests: None declared |
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John J Frey III, Madison, Wisconsin Professor of Famiily Medicine
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When I asked my sister, the high school English Teacher, retired after 33 years at the toughest school in her city, what she thought of the scoring system behind "No Child Left Behind" her comments reminded me of much of what I hear from family medicine colleagues about pay for performance. She said that teaching to scores in a school system like hers where less than 60% of the students finish because of community or family disparities seems impossible compared to suburban schools with intact families and lots of resources. I thought of that as I received my notice from the health plan that my heavily uninsured, non-English speaking diabetic patients with two jobs were not getting their HgbA1C levels under 7. Life is certainly not a level playing field for patients and neither is practice. All teachers, just like all family doctors, are committed to quality - or at least trying for it. But McDonald and Rowland's article comparing well compensated British GP's with support for overhead and something to gain but nothing to lose with over worked, underpaid family doctors in California who have 30% of their compensation to lose and little overhead support with which to do it does not result in many surprising findings. Practicing to meet standards rather than improvement or care is a demoralizing task and makes doctors want to find "easier" patients. The sources of dysphoria in primary care are not hard to identify and most P4P programs in the US are not helping things at all. And when new evidence comes out that should change or at least soften the "guidelines" and targets, they are ignored. That might force them to admit that quality might be about process rather than metrics. The highest rate of improvement in primary care in the US is in the Veteran's Adminstration system, once reviled but now widely emulated. The primary care doctors there work for a salary and have lots of support for their work, and get merit pay based on group performance, not individual achievement. Maybe U.S. insurance companies might learn something from that - if they choose to. Competing interests: Associate Editor, Annals of Family Medicine |
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Howard B Beckman, Rochester, USA Medical Director, RIPA
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This well conducted qualitative study supports the notion that the design of quality improvement programs plays a major role in determining outcomes. Too often practitioners see themselves on the outside of decision-making. To be successful, evaluation programs must involve practitioners early in the process and respond to substantive criticisms about accuracy and validity of the data used. In that way, the measures can be internalized and the financial incentives become less intrusive. McDonald and Roland describe that process as follows, "The potential adverse effects of external incentives on motivation are likely to be diminished where individuals identify with the goals and values of incentive programs and feel that they have a degree of autonomy in their delivery. In other words, when designing incentive programs, it is important to consider the manner in which they are implemented and the extent to which the context is perceived as supportive." These are some of the pillars of relationship-centered care. Accountibility is best accomplished through partnership to improve care rather than a simple "market" reponse to financial incentives. Competing interests: None declared |
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L. Gregory Pawlson, US Exective Vice President of NCQA (internal medicine physician-health services research by background)
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The careful study of the perceptions and feelings of physicians participating in pay for performance programs in California (IHA) and England should be read by all involved in physician practice evaluation and reporting-including pay for performance. While many of the perceptions can be challenged by empiric findings (for example, the studies of the VA incentive program by RAND-UCLA indicated that there was no decrement-and in fact in many cases an improvement, in areas NOT included in the incentives program), since involvement of physicians in practice improvement is perhaps the most important outcome of any type of incentive or evaluation program, physician motivation is important. While it is not clear from this study if these perceptions are held by all or even most physicians particpating in the programs, the fact that they are present require us to consider and, if possible, to address the issues raised. However, given the widely documented problems and disincentives of fee for service payment, we should not see these findings as justification for the status quo, especially in the US. The deeper and broader acceptance of the British physicians is, I would surmise, mostly a testiment to the fact that their payments were increased by 30% or more- and that GP's in Britain are now paid on a balanced, three tier system (FFS, capitation and incentive) that would seem to align them much more closely with "doing what is "right" for the patient with minimal influence from the type of payment. Hopefully the evolution of payment for primary care in the US, including payments linked to the Patient Centered Medical Home, and an overall, at least relative increase in reimbursement for primary care services, can bring us closer to alignment of professionalism with the unavoidable business aspects of medicine. Competing interests: I am engaged in developing and testing measures (HEDIS) that are used in all aspects of evaluation and reporting including pay for performance |
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