PFP vs. P4P: Physicians Foment and Protest against Pay for Performance

Posted by Sten Westgard, MS

This week two Harvard doctors wrote an op-ed for the Wall Street Journal: Why 'Quality' care is dangerous (subscription may be required, depending on time of access). In this essay, they warn of the dangers of what they term the "quality metrics" that provide the basis for "pay-for-performance" systems that may govern physician reimbursement. Under any of the proposed healthcare reforms, P4P schemes may be used as a way to "incentivize" doctors and clinicians to provide the right care to their patients.

One example the doctors use is Tight Glycemic Control:

A colleague who works in an ICU in a medical center in our state told us how his care of the critically ill is closely monitored. If his patients have blood sugars that rise above the metric, he must attend what he calls "re-education sessions" where he is pointedly lectured on the need to adhere to the rule. If he does not strictly comply, his hospital will be downgraded on its quality rating and risks financial loss. His status on the faculty is also at risk should he be seen as delivering low-quality care.

From the perspective of the doctors, the pay-for-performance systems are flawed because they might be based on the wrong quality metrics. In the case of Tight Glycemic Control, a new study has cast this practice into doubt, finding that a group of patients with TGC fared worse than a group of patients that did not. Should we really be paying doctors to do the wrong thing?

We share these concerns that such P4P schemes may be untenable, but for a different reason. The underlying imprecision and bias inherent in the analytical methods may make useful cutoffs for payment impossible or - worse still - easily to manipulate.

If you don't take into account within-subject biologic variation, method imprecision, and method bias, you could have patients jumping over and under these P4P cutoffs, while clinically there is no difference in their health state. But that variation will be raising and lowering the reimbursement. Or, in the case of that aforementioned colleague, causing him to attend re-education camps.

Now imagine, if you will, a new P4P scheme that provides a bonus payment if you can keep a certain percentage of your patients under level X of test Z. By a shrewd analysis of instruments and methods, you may determine that by switching from brand A to brand B instrument, you'll shift the values of your patients lower and move just enough patients into the favored category - without changing treatment at all. The opportunities to game such a system are manifold.

The Harvard doctors conclude that we need a "time-out" to check on the usefulness of these quality metrics. We suggest that some laboratory professionals be present at that time-out. We can provide advice that no one else can - information crucial for choosing tests where cutoffs are both practical and truly useful.

Labs will be vital in determining quality metrics that can help everyone. Let's hope someone notices it.