Will Pay For Performance Work in Medicine?

T he idea of paying for achieving a pre-determined goal isn’t foreign to most people. Even the government is trying to put this idea to work in the “no child left behind” program, with payments to schools being based on performance. And now we’re seeing a push for this in medicine. But will pay for performance work in medicine? I doubt it. Is it on its way? It seems to be. Tracking Performance The wheels have already been turning. The Veterans Administration has already been tracking primary care doctors’ performances. Indicators of “quality” have included general preventive services (vaccinations and screenings) and specific services for diabetes (good glycemic control, annual diabetic eye exam), hypertension (good blood pressure control), or prior myocardial infarction (use of beta-blockers or aspirin). Managed care organizations have been rated for some time. Large HMOs have tracked doctors’ performances on the basis of patient satisfaction and have linked pay to performance. Regulators have identified standards for performance in primary care and are seeking standards for specialty care. These standards will be easily tracked and quality of care undoubtedly will improve as measured by these standards, though I doubt they will result in patients actually getting better care. Useless bureaucratic measures may increase costs and worsen care. But maybe, just maybe, if we were in charge of the measures, some rational, if not useful, measures could be put in place. For example, in dermatology, people with a history of melanoma should have a complete skin examination at reasonable intervals, and patients with a history of skin cancer should be counseled about sun protection. Probably no one would argue with these parameters, but then patients probably are getting this level of care already. So let’s consider a few others — ones that might improve the cost-effectiveness of care, if not actual quality. • Basal cell and squamous cell carcinomas smaller than 3 cm should be removed in a physician’s office, not in ambulatory surgical centers or hospital operating rooms. • Patients should have basal cell carcinomas less than 2 cm in size removed under local anesthesia, not general anesthesia. Some operating room-based surgeons may not be happy with these guidelines, but they are only guidelines. It wouldn’t mean surgery couldn’t be done in other settings, only that physician pay would be higher for the more cost-effective setting. Higher in the sense of relative to the alternative, that is; nobody expects that pay would increase for meeting standards; far more likely, it will decrease for not meeting those standards. Determining Measures In principle, the concept of pay for performance doesn’t bother me. In practice, it’s hard to imagine bureaucrats coming up with any measures that will meaningfully improve the care we provide. Had we wanted to fight pay for performance, I wonder if we should have fought the principle when it applied to accountability for public funding of eduction. Too late for that now. But as the doctors who understand skin disease management, we have still have the opportunity to shape the measures that will be used. We should take advantage of this opportunity. Please send any pay for performance criteria suggestions you have to sfeldman@wfubmc.edu. Steven R. Feldman, M.D., Ph.D. Chief Medical Editor

T he idea of paying for achieving a pre-determined goal isn’t foreign to most people. Even the government is trying to put this idea to work in the “no child left behind” program, with payments to schools being based on performance. And now we’re seeing a push for this in medicine. But will pay for performance work in medicine? I doubt it. Is it on its way? It seems to be. Tracking Performance The wheels have already been turning. The Veterans Administration has already been tracking primary care doctors’ performances. Indicators of “quality” have included general preventive services (vaccinations and screenings) and specific services for diabetes (good glycemic control, annual diabetic eye exam), hypertension (good blood pressure control), or prior myocardial infarction (use of beta-blockers or aspirin). Managed care organizations have been rated for some time. Large HMOs have tracked doctors’ performances on the basis of patient satisfaction and have linked pay to performance. Regulators have identified standards for performance in primary care and are seeking standards for specialty care. These standards will be easily tracked and quality of care undoubtedly will improve as measured by these standards, though I doubt they will result in patients actually getting better care. Useless bureaucratic measures may increase costs and worsen care. But maybe, just maybe, if we were in charge of the measures, some rational, if not useful, measures could be put in place. For example, in dermatology, people with a history of melanoma should have a complete skin examination at reasonable intervals, and patients with a history of skin cancer should be counseled about sun protection. Probably no one would argue with these parameters, but then patients probably are getting this level of care already. So let’s consider a few others — ones that might improve the cost-effectiveness of care, if not actual quality. • Basal cell and squamous cell carcinomas smaller than 3 cm should be removed in a physician’s office, not in ambulatory surgical centers or hospital operating rooms. • Patients should have basal cell carcinomas less than 2 cm in size removed under local anesthesia, not general anesthesia. Some operating room-based surgeons may not be happy with these guidelines, but they are only guidelines. It wouldn’t mean surgery couldn’t be done in other settings, only that physician pay would be higher for the more cost-effective setting. Higher in the sense of relative to the alternative, that is; nobody expects that pay would increase for meeting standards; far more likely, it will decrease for not meeting those standards. Determining Measures In principle, the concept of pay for performance doesn’t bother me. In practice, it’s hard to imagine bureaucrats coming up with any measures that will meaningfully improve the care we provide. Had we wanted to fight pay for performance, I wonder if we should have fought the principle when it applied to accountability for public funding of eduction. Too late for that now. But as the doctors who understand skin disease management, we have still have the opportunity to shape the measures that will be used. We should take advantage of this opportunity. Please send any pay for performance criteria suggestions you have to sfeldman@wfubmc.edu. Steven R. Feldman, M.D., Ph.D. Chief Medical Editor