Tuesday, March 15, 2005

Pay for Performance

Medicare has a pilot program that sounds intriguing, at least on first glance. Basically, it is a plan that is designed to reward good patient outcomes. To put it simplistically, if a physician provides good care for his/her patients, and those patients have good outcomes, that behavior is rewarded. On the surface, that sounds fairly reasonable, and certainly looks as if it can be applied to many facets of health care, such as diabetic care, cardiovascular surgery, hip replacement, etc. Those arenas tend to have fairly readily defined parameters for care and outcomes.

Unfortunately, the delivery of medical care is not something that can be easily rated, as there are innumerable complex issues that tend to confound the actuarial analysis of data. The data itself is hardly easily defined; who gets to decide what is clinically relevant in the care of a patient? For example, is it a "complication" of an abdominal operation for a patient to have an (expected) postoperative ileus? If a patient is reluctant to follow a physician's recommendations, will it reflect negatively on his "grade?"

As a surgeon who cares for often very sick patients on a routine basis, I am hopeful that there can be some system devised that recognizes the difficulties encountered when multiple medical (as well as social) issues complicate the ultimate outcome of individual patients. I am skeptical, however, that such a system will be fair in rating those of us who do not turn away the very sick, the elderly, and the complex patient. I worry that it will encourage physicians to avoid those patients like the plague, lest they become a "pox" on their Medicare-approved rating. In my field, we'd be left with legions of general surgeons "qualified" and willing to take out gallbladders and fix hernias in the under 40 age bracket, and no one left to care for the 86-year-old with an obstructing colon cancer.

Medpundit has a few well reasoned thoughts about this as well from a primary care perspective. She asks perhaps one of the most salient questions about this initiative:

In the long-run, what will happen to those patients who can't achieve numerical perfection? Or who can't quit smoking? Or who just can't bring themselves to have a colonoscopy? Will doctors refuse to take them on as patients, knowing they won't get paid for taking care of them? It would be a very mercenary thing to do, but it's likely to happen. A doctor who can't pay his bills is a doctor who can't practice medicine.