Sunday, June 1, 2014

Does Pay for Performance Measure Medical Quality?

If you read this blog, then you likely know about the scam known as Pay for Performance (P4P).  This program not only fails to deliver on its stated mission to improve medical quality, but it actually diminishes it.  For a fuller explanation on why this is true, simply insert ‘Pay for Performance’ into this blog’s search box, and grab some Rolaids. 

In short, P4P pays physicians (or hospitals) more if certain benchmarks are met.  More accurately, those who do not achieve these benchmarks are penalized financially.   I do not object to this concept.  Folks who perform at a higher level should be rewarded accordingly.   My objection is that the benchmarks that have been selected are arbitrary and too far removed from true medical quality measurements.  Benchmarks have been chosen that are easy to measure even if these measurements don’t count for much.  In other words, what really counts in medicine, isn’t easy to count or measure.

Medical Quality Measurement Instrument

Consider the following physician vignettes:
  • A surgeon advises against proceeding with surgery as he feels that in 48 hours recovery may begin.
  • A pediatrician makes a series of phone calls to arrange for a social worker to become involved in a challenging home situation.
  • A family physician tells a patient that a CAT scan is not necessary for his condition.
  • An internist recognizes that a patient’s new symptom is a side effect of a recent medication, which he stops.
  • An emergency room physician sees a patient with a cough and notices a suspicious mole on the patient’s back.  He sends the patient to a dermatologist.
  • A gastroenterologist carefully palpates a patient’s abdomen and discovers that the spleen is enlarged.  This begins a path that leads to an unexpected diagnosis. 
  • An internist takes a thorough medical history letting a patient tell his story without rushing him or cutting off his responses. 
  • An oncologist doesn’t advise futile cancer treatment, even though it could be presented to the patient and family in a manner that they would accept it.  
  • A hospitalist communicates all relevant medical information, including unfinished or pending issues, to the internist who will be assuming care of the patient after hospital discharge. 
  • A psychiatrist saves a patient’s life who had contemplated ending it.

These examples illustrate what I think is very high quality medical care.   But, since there is no way to reliably measure them, they don’t count in the Pay for Performance schema.  So instead, the government and insurance companies will measure lots of dumb stuff and then dock us when we don’t measure up.

This has nothing to do about real medical quality, but it has everything do about cost control.  If the P4P enterprise were paid on its performance, they would be out of business.   Shouldn’t they have to be subjected to the same rules that they impose on the medical profession?


  1. If you want to improve health care in the us there needs to be a system of accountability and currently there is none. You know better than I do that state medical boards are a joke.

    The US medical industry commits more fraud in terms of dollars than all other industries in the entire world combined.

    In spite of the fact that American MDs are the highest paid in the world they still commit the most errors and fraud.

    Let's take medical criminal Rick Scott and Columbia HCA. In spite of a 1.7 BILLION dollar fine Slick Rick waltzed away with his golden parachute and the morons in Florida elected him governor. Rick Scott and former senator Dr Bill Frist should be doing hard time.

    You can't make cockroaches all that accountable by being nice and offering carrots when these guys are on the kickback gravy train.

    Here is how you fix health care.

    1. Start curing diseases.

    2. Make the Hippocratic Oath law

    3. Punish criminal negligence and fraud.

    Do you realize that health care is the only industry that profits more from being incompetent than competent?

    Click Here Medical Industry Steals More Than the Bankers and Kill More Than the Nazi Holocaust

    The fundamental problem is the corporate monetization of disease and human suffering for obscene profit.

    I hope you publish this.

  2. This comment has been removed by a blog administrator.

  3. Your post is spot on, Dr Kirsch.

  4. There is only one way out of this mess, and that is for all the physicians in this country to simply refuse to participate in the Obamascheme. If we trust Congress to relieve our medisurance suffering we are fools. I live in a community whose population is primarily geriatric patients. My rheumatologist says he's $250K in debt because Medicare pays so little, my ophthalmologist (large practice of many docs & many offices) says he's barely getting by, my cardiologist (multiple docs; cath center +) says he's only staying in practice because he has three kids in college or else he'd quit, and the only ones making any money at all are the interventional cardiologists and surgeons. This can't go on! Medicare stopped paying for meds, so I had to stop my meds. Where does that leave me? Government health care is genocide, plain and simple. The elderly and chronically ill are being systematically destroyed.