Pay-For-Performance, Setting Patients up for Higher Bills?

The letters to the editor, in response to the Times article I wrote about previously, viciously point out the inherent problems with a PFP reimbursement approach. You can read some of them HERE. A good point: "If hospitals are forced to provide free corrective treatment to victim patients, those costs will become part of hospital overhead, which we will all pay for anyway." Is that all that PFP does, skips the bill so that both providers and patients are left with the difference?

Another question we have to ask when debating PFP is whether this system demands no errors in an industry that cannot exist without some errors. Although we would love to avoid every preventable accident in medicine, it may be dangerous to punish an industry that relies on risk/benefit ratios, experimental treatments, and other efforts to treat diesease. From one of the letters:

"It is important to understand the context in which medical events like catheter-related urinary tract infections and pressure ulcers occur in hospitalized patients.

These patients have multiple chronic medical problems and are often immobile and institutionalized, having lost the ability to care for themselves because of diseases like Alzheimer’s or severe stroke. Others are in intensive care units suffering from multisystem organ failure and on the verge of death.

Therefore the analogy to use should not be one of an auto mechanic accidentally breaking the windshield while repairing the engine. Rather, it should be of the mechanic who is required to perfectly repair a vehicle that arrived at the shop totaled."

One Step Closer to Pay-For-Performance Medicine

There is a current running through healthcare policy think-tanks, insurance company board rooms, and government offices. Pay-for-Performance (PFP) is coming and coming fast. Not a soul is selling PFP as a key to medical utopia, but it is a decisive movement toward broad reform of medical reimbursement. PFP restructures reimbursement of providers from the current quantity-driven method to a what is supposed to be a quality, error-minimizing way. It does this not only by providing incentives for positive outcomes but also withholding payment when treatment is due to a "reasonably preventable" error. Its proposed benefits to the system are financial incentives toward quality control and minimizing preventable accidents, infections, and injury by providers. Its critics however have a decent leg to stand on. They claim that under these plans physicians begin cherry-picking low-risk patients, for instance for cardiac bypass surgery. This way, their successful outcomes looks very high upon analysis by medicare or an insurance company, and they recieve bonuses and/or high recommendations by what would be a public rating system of doctors and hospitals.

The most recent and apparent shift toward PFP is medicare's plan to withhold reimbursement for medical errors. This is the beginning, as most insurance companies will follow medicare as they normally do. This New York Times article lays out the new plan by medicare. What I found interesting was that although this is supposed to be a money-saver for these insurers, studies and experiments have shown little if any savings. The article points out that:

"The real money, many health economists believe, may come from reorienting the payment system to encourage prevention and chronic disease management and to discourage unnecessary procedures."

This astonished me. Have insurers and the government finally realized that investing in these preventable and manageable diseases now, you will have a healthier and thus cheaper patient population later? Who knows, and beyond that question, we don't know if this reimbursement plan will even redirect the medical community's attention to these issues. Time will tell, but now we know that PFP is on its way, whether physicians like it or not. I think it is now our responsibility to educate ourselves about it, so that we can make informed decisions in our future as physicians.