Friday, April 08, 2005

Pay for Performance II

I just received the new edition of the "throw-away" mag Surgery News ("The Official Newspaper of the American College of Surgeons"). Unfortunately, there is no online edition to refer readers to. It contains an article written by Joyce Frieden entitled "Is Pay for Performance Premature?" which echoes some of the themes in my post from a few weeks ago. CMS Administrator Mark McClellan, M.D. is quoted as stating that physicians are not the major cost issue for Medicare (emphasis is mine):

"Physicians account for a small fraction of total costs, but doctors have a lot of good ideas and they have the knowledge it takes to get more results for what we actually spend....I think [pay for performance] can potentially save significant amounts of money. At the same time, we're also going to be paying attention to clinical equality."

Me thinks he speaks with forked tongue! There is no question that physicians have a lot of good ideas about how to care for patients in a cost-efficient manner. Who orders the diagnostic tests? Who is (or is not) available for patients to see on an urgent basis, which alters ER volume? Who rounds on patients more than once a day in the hospital to decide which patients are ready to go home? But who has been left out of the development of this pay for performance plan, and who is the target of its ultimate goal of cost cutting? What I fear is yet another layer of Medicare bureaucracy to deal with to make sure that all of the "performance" guidelines are met --- nurse administrators carrying lists of checkoffs to be sure that every patient gets a flu vaccine, every physician follows the latest beta blocker recommendation from the American College of Cardiology, etc. .... but without the simple clinical insight to decide whether it is appropriate for each individual patient. How is this plan to be administered and monitored for the huge numbers of physicians who practice solely in the outpatient setting? Will this further intrusion cause an even greater number of primary care physicians to stop seeing Medicare patients (an already significant problem in my community)?

  • Evaluating whether patients receive appropriate care can seem simple, but rating the process is convoluted and prone to error and abuse. I can give two very simple examples of this which every physician can relate to.
  • When I was in my last year of surgical residency, the VA hospital associated with our program went through JCAHO evaluation while I was rotating there. It was common knowledge amongst the nursing staff and residents that the most problematic department on campus was Respiratory Therapy --- slow to respond to urgent calls, inappropriate with patients, and (most worrisome) there was only one RT available from 6PM until 8AM, a potentially life-threatening issue in a hospital campus with 6 separate buildings full of sick chronic smokers. Their paperwork, however, must have been impeccable -- RT was the only department to receive the highest level of commendation from JCAHO during that inspection.
  • About two years after I started practice, one of the other general surgeons in town pulled me aside to let me know quietly about some concerns that had been raised in Peer Review. It had been noted that I had a disturbing rate of prolonged postoperative ileus! When the surgeons on the panel actually looked at my charts, what they found was my (then frequent) notation after a bowel resection or enterolysis that we were "awaiting resolution of post-op ileus." The hospital's coders, under orders to squeeze every dollar out of Medicare possible, listed this expected process as a complication, even though my postoperative discharge date averaged lower than the general surgeons practicing at the hospital!
My point in citing these two examples is that documentation of quality care is far from an exact science at this point. I think CMS knows this, and is using this as a tool to further decrease physician reimbursement. Doctors do know how to decrease overall costs, and have been railing about one glaring example for years - tort reform - which is not mentioned at all by health care policy pundits as a viable option.

Finally, what if we find that good quality care is more expensive, rather than a means to control costs? Another part of the article quotes Denis Cortese, M.D., the president and CEO of the Mayo Clinic:
"I noticed that performance was defined as reducing costs. I was tempted to ask, 'What happens if the quality goes up and the cost goes up with it?' If the value rises higher than cost, are they really going to pay for it? I don't believe they will."


Unfortunately, neither do I.