John W. Rowe, MD
Note: This article is based on the Harvey Kimball lecture given by the author at the 2005 American Board of Internal Medicine Summer Conference.
Grant Support: None.
Potential Financial Conflicts of Interest: Employment: Aetna, Inc.; Stock ownership or options (other than mutual funds): Aetna, Inc.
Requests for Single Reprints: John W. Rowe, MD, Columbia University, Mailman School of Public Health, 600 West 168th Street, 6th Floor, New York, NY 10032; e-mail, Jwr2108@columbia.edu.
Value-based purchasing, or pay-for-performance, is a major emerging theme in U.S. health care. Forces enhancing adoption of pay-for-performance programs include continued increases in medical costs beyond overall economic growth, a body of evidence that the quality of health care provided to patients is not directly related to the volume of services received, increasing evidence to serve as a basis for the development of standards against which to measure clinical performance, and increasing acceptance by physician organizations and individual practitioners of the rationale underlying these efforts. In this context, employers, government payers, and health plans are establishing a wide variety of pay-for-performance programs. This article reviews the critical design features of such efforts, describes the current types of programs on offer, and comments on the implications of this emerging movement for the future of health care in the United States.
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Christine A. Sinsky
Medical Associates Clinic and Health Plan
November 10, 2006
Assumptions in P4P
Rowe (1) makes several important points about value based purchasing, especially the need to develop meaningful measures for complex patients and the tension between rewarding the absolute level of achievement vs the degree of improvement. Four assumptions within the paper, however, deserve comment: the assumption that HIT is the cure for quality; that extra patients aren't really extra work, that primary care physicians are not specialists, and that performance measurement should be focused at the physician level.
The author refers to the "obvious advantage" of an electronic health record (EHR) in achieving quality. I believe that to be a long-term probability, yet it is not a current reality for many who are using electronic health records. Existing products are too raw, the technology is too immature, and there is a serious lack of human factors and efficiency input into design. HIT has not yet lived up to its potential. In 2 years experience with an EHR at our clinic and 1 year with EHR and CPOE at our hospital I have seen quality compromised as a direct result of the technology.
Rowe claims that selective referral will increase physician income because "the income from these "˜extra' patients is mostly profit". Extra patients are extra work, and require additional physician and staff resources. They are not "mostly profit". There is a vein of magical thinking in medicine that implies physicians can do extra work in little or no extra time. (Everyone's pet project is added to the primary care specialist's slate of responsibilities with the offhand remark "it only takes a few more minutes to"¦") There are few economies of scale for personnel time, the most costly resource in an office practice. More patients per week mean more office hours per week, and more physician and staff time for pre-appointment, post-appointment, and inter-appointment management tasks.
General internists and family physicians are specialists in primary care. Our colleagues in cardiology, GI, ophthalmology etc. are single system specialists. It does not advance equity within the health care system to reinforce an outmoded hierarchy that implies greater value for one group of physicians over another ("specialist" implies "special"), particularly in the context of a discussion of physician reimbursement.
Rowe focuses primarily on performance measurement at the physician level. Since most quality is driven by systems at the organizational level, I believe the emphasis of measurement should also be at the systems level.
no direct academic affiliation
November 15, 2006
Pay for Performance / the Orwellian answer to cost control
I became a cynic early on when it came to the Golden Rule. My father's interpretation, "He who hath the gold, rules" seemed suitable in the world where I grew up. The emergence of Pay for Performance as illustrated by John Rowe, MD is the medical version of my dad's "Golden Rule".
Medicare in 1965 emerged and the patient-doctor relationship dissolved into the patient-fiduciary (health plan)-physician cooperative. As the cost of care increased (as one would only expect in any first dollar coverage system), the fiduciary, often a for-profit corporation, needed to cut expenses while increasing market share in order to maintain a profit margin.
HEDIS emerged but there was never any good evidence that "health care" was improved. Employers wanted their money's worth and pay for performance was born out of the physicians' need to emerge out of their bankrupting office practices and health plans' need to differentiate themselves from other plans in the same market place.
The problem is that there is no data to support the "performance". Healthcare data is scant at best and fails to legitimately document the "best" evidence for most every procedure or hospital occurrence.
Physicians have yet to evaluate what they "sell" and patients have no basis for a value-based purchase. In some circumstances, one medication may be better than another but the statistical basis is poor and few physicians ever take the time to articulate the statistical significance and its relevance to a specific patient centric plan of care during a health plan compensated 9 minute (on average) patient visit.
Pay for performance is a ruse. There is no additional money in the system to pay for "excellence" as defined by these arbitrary "what's good for one, is good for all" pradigms and many physicians will be forced out of business, making it more and more difficult for even the best doctors to have the time to listen and do the best for their patients.
The only way to credibly pay for any value based product is for the purchaser to pay for it directly not thru a third party that could not possibly know what is best for any specific circumstance.
My patients are individuals with specific medical and social needs to help them have "a better day". The purchase of a health care decision or product is nothing akin to the purchase of the best tasting cherry pie or an aged grade A piece of beef. I do not base my medical recommendations to my patients on how I will be rewarded excepting, of course, knowing the ultimate reward of knowing that that I did the right thing.
In a legitimate capitalist system driven by Keynesian economics, any purchaser must have full knowledge of the product and make a decision to purchase based on the value to him or her. On the other hand, population based/health plan driven health care decisions promoting a non-evidenced based pay for performance scheme is Orwellian and I believe best kept back in a library under the cover "1984".
Department of Internal Medicine, Easton Hospital, PA 18042
November 20, 2006
P4P "“ Boon or Bane for the American patient?
How much of the clinical outcomes are actually based on physicians care? This is the basic question we need to address before we discuss the pay-for performance (P4P) initiative. A well-designed study on managed care patients clearly indicated that patient factors substantially influenced outcomes. The cost of medications, age and sex of the patients were among many things that determined if patients decided to follow their doctors' advice (1). It is also well known that racial and ethnic disparities already exist in our healthcare system (2). Besides, it is suggested that adhering to current clinical guidelines in older adults with multiple co-morbidities may have undesirable effects (3). With this background, let us examine how the P4P program may affect some Americans.
Rowe (4) explicitly states in his article that the basic premise of the P4P initiative is that the physicians will respond to financial incentives and also voices his concern about practitioners trying to "game" the system in order to achieve these incentives. It is thus logical to presume that physicians would not want to deal with patients in their practices that are perceived as financially unrewarding. This group of patients unfortunately includes sick and elder Americans with complex medical disorders and the middle and lower income families. These individuals need healthcare the most and have difficulty achieving excellent health outcomes because of factors like rising health premiums, higher deductibles, less than optimum prescription coverage and poorer access to quality healthcare. Physicians typically spend more time to address their social situations, in addition to their medical problems. Often, cheaper and possibly less effective alternatives have to be tried for these patients, thus precluding the desired best clinical outcomes. With the P4P program, there would be even less incentive for physicians to care for these patients. Our healthcare system cannot risk making access to quality healthcare more difficult for some, while achieving overall better outcomes in others.
We clearly need more value for our healthcare dollar and a well- implemented P4P program will be a good start. But, public health policy makers should understand that while it is a laudable goal to achieve cost effective and quality healthcare, it should not be done at the cost of isolating certain subgroups of the population from procuring that quality product. The P4P program should not be thrust too quickly on the medical community without consideration of these potentially undesirable consequences. Rather, it should be a collaborative effort after careful discussions with practicing physicians, organizations like the American Association of Retired People (AARP) and minority group representatives.
1. Schultz JS, O'Donnell JC, McDonough KL, Sasane R, Meyer J: Determinants of compliance with statin therapy and low-density lipoprotein cholesterol goal attainment in a managed care population. Am J Manag Care. 2005 May; 11(5): 306-12. [PMID: 15898219]
2. Betancourt JR, King RK: Unequal treatment: the Institute of Medicine report and its public health implications. Public Health Rep. 2003 Jul-Aug; 118(4): 287-92. [PMID: 12815075]
3. Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW: Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA. 2005 Aug 10; 294(6): 716-24 [PMID: 16091574]
4. Rowe JW : Pay-for-performance and accountability: related themes in improving health care. Ann Intern Med. 2006 Nov 7; 145(9): 695-9. [PMID: 17088584]
Christine K. Cassel
November 28, 2006
To the Editor:
ABIM is pleased that the Kimball lecture given at the 2005 ABIM Foundation Forum was published. It is an annual lecture in honor of Harry Kimball (not "Harvey" as stated in the acknowledgments), ABIM and ABIM Foundation CEO from 1990-2003.
It is also important to point out that Dr. Rowe is incorrect in his statement that Maintenance of Certification (MOC) does not measure quality frequently enough to be relevant to pay-for-performance programs. To the contrary, in the past year several major regional and national health plans"”including Dr. Rowe's former company, Aetna; but also UnitedHealthcare, and Blue Cross and Blue Shield plans in Nebraska, New Jersey (Horizon), and Pennsylvania (both Highmark and Independence)"”have recognized the relevance of board certification and recertification by incorporating them in their reward and recognition programs , and many more appear poised to do so. It is particularly important to note that "the utility of these professional databases" has not "been limited because"¦some certification programs measure performance at 10-year intervals." In fact, these health plan programs reward physicians who measure performance annually or every-other-year, through the MOC process.
While the total cycle is ten years, Maintenance of Certification in any of the ABMS specialties is intended to become a series of assessment activities over the course of the ten-year cycle. The alignment of health plan incentives with professionally led efforts to measure and improve care can significantly reduce the burden associated with collecting data for both purposes. ABIM is committed to making the measurement associated with MOC both timely and clinically relevant.
Christine K. Cassel, MD, MACP President and CEO, American Board of Internal Medicine
1.Rowe JR. Pay-for-Performance and Accountability: Related Themes in Improving Health Care. Ann Intern Med 2006;145:695-699.
2.American Board of Internal Medicine. Health Insurers Work With American Board of Internal Medicine (ABIM) to Reduce Physician Quality Data Reporting Burden. Press release issued June 28, 2006. http://www.abim.org/pressroom/pres_release/06_06_28_burden.shtm (accessed November 6, 2006).
John W. Rowe
February 8, 2007
Response of Dr. John Rowe to Letters to the Editor
In response to Dr. Cassel:
In my paper, I indicated that the recertification databases developed by certifying boards may be of limited utility for P4P programs "because some certifying programs measure performance at 10-year intervals". I appreciate Dr. Cassel's note that the American Board of Internal Medicine's Maintenance of Certification program affords physicians the opportunity to assess their clinical performance regularly throughout a ten-year recertification period. If the recent trend for health plans to recognize these assessments in their reward programs spreads more widely and many more physicians participate, my skepticism in this regard may prove unfounded.
In response to Dr. Sinsky:
I concur with Dr. Sinsky's view regarding the gulf between promise and practice in HIT. However, some organizations, such as the Veterans Administration and Montefiore Medical Center in New York, have made real progress. Dr. Sinsky questions my focus on individual physicians, because quality is often driven at the systems or organizational level. Since most U.S. physicians practice in solo or very small groups, a primary focus on the clinical performance of individual physicians is warranted.
Dr. Sinsky disagrees with my view that referring additional patients to specialists, such as orthopedists and cardiac surgeons, will increase physician income disproportionately. While these patients require as many resources as others, my experience as CEO of a large medical center leads me to conclude that extra "marginal" patients add significant financial value once the fixed costs of operating the practice have been covered.
In response to Dr. Krishnamurthy:
I concur with Dr. Krishnamurthy regarding the critical importance of patient factors in the effectiveness of P4P efforts. Physicians must not be penalized for performance measures that are determined more by characteristics of the patients they choose to serve than their efforts.
In response to Dr. Zwelling:
I agree with Dr. Zwelling on the need for more evidence to support the establishment of standards, against which the clinical performance of physicians is measured. A glaring deficiency is the lack of suitable information on the comparative effectiveness of various medications, devices, and procedures. The relevant clinical data base is growing rapidly and we should use the information currently available rather than waiting for perfection of the evidence.
I do not agree that the lack of additional money makes P4P a ruse. Where in the logic for P4P is the promise of increased overall payments for physicians? As I indicated in my paper, P4P is, ultimately, about paying higher-performing physicians more and lower-performing physicians less.
Edward J. Volpintesta
June 6, 2007
Pay for performance:final pathway to dehumanization of doctors
Perhaps the most important statement made by the author was the very last one in his article: "It is hoped that the payment system will learn to reward the personal qualities that patients continue to seek in their physicians". The significance and implications of this statement are monumental and not nearly discussed enough. Physicians are living in an era in which science has come to dominate and define every area of what they do. It has become so strong, or perhaps headstrong is a better word, that it has pushed aside the humanistic qualities of medicine that should separate it from all other professions. Doctors are rapidly losing their traditional roles as "doctors", that is, caring, concerned idividuals that make decsions based on common sense. This has been made worse of course by the legal imperative to do everything to prevent malpractice suits. Still it could have evolved differently had the medical leadership spoke out and defended the humanitarian roots of the profession.
Things worsened when medicine adopted the language of the workplace: concepts like productivity, quality,and pay-for-performance are all better suited for making radios and digital cameras. They have little or no application to human beings as patients. But now that they have achieved currency we are forced to use them. But if we do,lets at least be aware of the potential for harm that they carry.
What is that harm? Well by classifying doctors in such harsh and impersonal terms, there is a danger that doctors' sense of identity will be defined not by medicine's traditional qualtities but by the business world's profit-driven philosophy. And as physicians increasingly are working for either large medical groups,hospitals, and HMOs the opportunity and pressure to rationalize will only increase.
Doctors will come to see theselves as scientists-businessmen, having rationalized away all the soft qualities as being exraneous and meaningless. The profession will have been cleansed of its humnanitarian roots. Its already started.
The time is now to protect those personal qualites that bond physicians and patients:to identify them, reward them, and make them just as commendable and worthy of admiration as any other standards used to evaluate physicians.
Remedial education must always be positive and constructive
The author mentions that those physicians who have been in practice a long time have worse average scores on measures of quality and may be "targets' of remedial educational initiatives.
Remedial education is a good idea. Most of us do it voluntarily by reading and attending CME. But a little extra never hurts as long as its practical and tailored to one's practice.
Thus the educational initiatives the author alluded to have to be carefully thought out. They should not have any of the flaws of the ABMS recertification exams as they apply specifically to primary care doctors. Many of these physicians as time goes on tailor their practices to their capabilities, the needs of the community, the number of specialists in the area, and the revalent socieconomic standard.
Yet their recertification boards reflect a dogmatic approach. One that represents the ideal internist or family doctor. Fearful of not passing, some doctors force-feed themselves by taking board review courses memorizing material that they no longer need. Clearly, it is impractical and unrealistic to expect all physicians, particularly those in primary care to have the wide spectrum of academic knowledge they had at the end of their residencies or during the first few years of their practices.
In addition, the boards have a pass/fail approach which really is an insult to any physician who has been through an approved residency and passed a primary certification and kept his CME up to date. Failing a test that is ineffective in the first place and retaking it at much cost of time and money is an indication of how fragmented the profession has become and how much a common ideology is lacking.
The point is that any remedial education offered should point out areas of weakness to doctors and provide opportunities to improve. They should be constructive and positive. After all, doctors have spent a large part of their lives and made many sacrifices to get licensed. Its wrong for any board or certifying organization to use education to harm either a physicians' reputation or ability to make a living by "failing" him or her.
Impractiality and potential to harm physicians should never be a part of physicians' remedial exams.
Rowe JW. Pay-for-Performance and Accountability: Related Themes in Improving Health Care. Ann Intern Med. 2006;145:695–699. doi: 10.7326/0003-4819-145-9-200611070-00013
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Published: Ann Intern Med. 2006;145(9):695-699.
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