Hug your doctor today

Consumers know the pressures they’re under to comply with the health risk factors proposed by their insurer, but few realize that their doctor is under much the same pressures.

It’s called “pay-for-performance.”

The compensation doctors receive from major insurers, including those for Medicare and Medicaid patients, are contingent on how well they score on “performance-based” measures. These reward and penalize doctors based on the screening tests and labwork they order, the prescriptions they write, and their patients’ outcomes, using many of those same risk factors their patients are being judged on. Doctors must also report their data on electronic databases. Under Blue Cross Blue Shield’s plan, for instance, 5 to 10% of doctors’ payments can hinge on how they score. For Medicare patients, the government’s Centers for Medicare & Medicaid Services currently bases 1.5% of doctor’s reimbursements to their compliance with 74 measures, but the senior advisor and medical officer for the CMS said last December that “it could take as much as 20% to motivate physicians.”

P4Ps have been a topic of debate and concern among doctors since their development began in 1991. Doctors have a number of concerns about them.

Many doctors have said that a system which gives poorer grades to doctors whose patients are sicker is perverse. They’re concerned that the financial incentives could mean the sickest or most difficult to treat patients would be less likely to be accepted into doctors’ practices and might have a harder time getting care. Last month, the American Medical News reported that 82% of doctors said the quality measures would have unintended consequences by their avoidance of high risk patients and that it would hurt minorities and the poor. As one doctor wrote: “The poor, unmotivated, obese and noncompliant would all have to find new physicians.”

Doctors are being put in the position of having to push their patients into complying with tests and prescriptions that they may not want, that won’t help them that much, or that their personal situations may mean are not best for them. Patient compliance is not under the doctor’s control and some patients may also not have the resources to comply. Poorer people may need to buy food for themselves and their children, rather than pay for prescriptions.

Last year, the American Medical Association, supported by Congress and the AARP, agreed to develop about 140 measures of performance that will be used by health care providers to judge doctors’ performance and determine Medicare payments. The performance measures are supposed to focus on diagnostic tests and treatments that are known to produce better outcomes for patients, according to the New York Times. [We’ll look in an upcoming post at who has been behind the development of the measures and who’s doing the measuring and accrediting.]

But the measures have been questioned for their soundness in the medical literature — such as their emphasis on physical exams and screenings that may be unnecessary, pharmacological interventions, the special interests behind their creation, and for emphasizing cost cutting and profits for insurers over quality of care for patients. By making measures one-size-fits-all, they may not be best for all. The measures don’t take into account and adjust for the severity of illness in individual patients or other characteristics about a patient and his/her circumstances that could influence outcomes. Most measures target individual diseases and were based on studies of patients with only one disease, but in real life, it’s common to have patients with multiple health problems and complexities that have to be balanced for the best interests of each patient.

If the evidence behind the clinical guidelines were strong and clear, there wouldn’t be so much disagreement to them within the medical community, controversies many consumers may not be aware of. Annual physicals for everyone, for instance, are being compelled by many insurers, but an expert committee sponsored by the Agency for Healthcare Research and Quality in 2003 found little benefit in many of the tests and suggested that they only serve to increase the cost of healthcare, while exposing patients to unnecessary risks. The other measures, such as weight management, adherence to lipid-lowering (“cholesterol”) and anti-hypertension (high blood pressure) medications, and diabetes management are equally controversial. As we’ve previously examined the weight management, cholesterol and blood pressure guidelines here, let’s look at another example.

A study led by Dr. Leonard M. Pogach, M.D., MBA, at the Health Services Research and Development Center for Healthcare Knowledge Management Research, Department of Veterans Affairs New Jersey Healthcare System, examined one controversial P4P measure. Under the clinical practice guideline of the American Diabetes Association, the target for glycosylated hemoglobin (A1C) level measurements are less than 7%. The doctors found that this arbitrary threshold had been achieved in clinical trials with resources not usually available in real-life clinical practices and that they are not appropriate for certain types of patients, namely older ones or those with comorbidities (other health problems). Examining the data on patients from 144 Veterans medical centers during 1999 and 2000, they found that more than one-third of the diabetic patients would never benefit from meeting the A1C values. Instead, the aggressive control of blood sugars necessary to achieve the low A1C levels brings dangers such as of hypoglycemia, that could increase their health risks and be dangerous or even fatal for certain patients.

In a powerful editorial in the same issue of the American Journal of Managed Care, Dr. Rodney A. Hayward, M.D., described the politics behind two performance measures for diabetic patients that were a compromise reached after a 5-year battle between “advocates of optimal goals (disease advocates) and advocates of simple, inexpensive performance measures (health plan leadership). Experts in medical evidence were not included in the compromise, which is part of the problem,” he said. The establishment of precise clinical outcomes, such as A1Cs of <7% and blood pressures of <130/80, were unusual in that in the past, measures are focused on the process of care patients receive, not outcomes. He said that the concept of “optimal” measures are “inaccurate, promote waste and perhaps cause substantial harm.” Benefits to individual patients will depend on the severity of their disease and response to treatment.

For example, “the majority of patients who achieve an ‘optimal’ treatment goal, like BP <130/80, are those with no or mild disease,” he said, yet the greatest preventable morbidity and mortality benefit is among the high-risk patients who may be less likely to achieve the ideal measure.

[U]sing BP <130/80, as a thin, bright line results in rating the care of a patient with a naturally low BP as good care, but does a poor job of distinguishing truly good care from truly bad care. Even after prescribing 3 or 4 antihypertensive medications and paying careful attention to medication adherence, those with severe hypertension will usually have persistent elevations of systolic BP. The irony is that the BP <130/80 measure provides greater rewards for speculatively treating patients with mild disease (no clinical trial has demonstrated aggressively treating people with DM [diabetes mellitus] with mild BP elevations is either beneficial or safe) and does a poor job of rewarding the treatments shown in clinical trials to produce dramatic reductions in disability and mortality, because only a small minority of the severely hypertensive patients studied in the clinical trials achieved a systolic blood pressure <130. Not only is there no evidence that using more than 3 or 4 medications in pursuit of the <130/80 goal is beneficial, but there is consistent grade B evidence that such treatment may increase cardiovascular mortality in those who have already achieved a diastolic blood pressure <70. This is not a rare event, a quick look at National Health and Nutrition Examination Survey data reveals that of patients 65 years of age and older, about a third of people with DM with SBP >130 already have a DBP <70, meaning that the new HEDIS measure will frequently be promoting care that the best available evidence suggests will increase cardiovascular mortality.

And you probably don’t want to hear this, but last month a study of existing state Medicaid P4P programs — almost half have been in operation for more than five years — found that very few states have evaluated their programs to know if they’re actually improving quality of care. The Medicaid directors themselves also raised concerns that complicated patients might be less likely to find care and that P4P might also result in doctors leaving the program.

The heavy hand of insurers on doctor’s practices extend to the referrals doctors make for their patients to see an out-of-network doctor, take nonpreferred medications or to receive diagnostic testing by labs and providers outside the network. You may have read about the UnitedHealth imposing fines against doctors who refer a patient to out-of-network care. While developing contracted lab and diagnostic providers can mean cost savings and is part of the contracts doctors have signed with insurers in order to care for their patients, the problem is that these actions have been applied to patients who’ve paid higher premiums for the right to access out-of-network benefits!

Because these P4P measures emphasize certain selected measures, doctors could be coerced to focus on them and ignore care issues that might be of greater need or importance to individual patients. Doctors are concerned these P4P may result in patient care focused on meeting the measures, rather than what’s best for each individual patient.

Last month, Dr. Westby G. Fisher, M.D., FACC, a board certified internist, cardiologist, and cardiac electrophysiologist in Evanston, IL, wrote a commentary on his blog in the form of a imaginary letter to his patients:

I regret to inform you that I will be spending less time focusing on your heart problem because I have decided to focus on the heart and medical problems that Medicare deems important to assure I get paid. They call this initiative “Pay for Performance (P4P)." You see they published a list of 74 criteria that will be measured to see if I give good care, so I will get paid appropriately....

So, dear patient, I'm sorry if you have pericarditis or heart block. I'm gonna need to focus on my heart attack and heart failure patients a bit more to make sure my office staff can still return your calls. I hope you understand.

In Medical Economics a few days ago, Dr. Richard J. Mansfield, M.D., wrote a powerful personal essay on the ethical dilemmas felt by doctors under P4P and how it is changing the way they practice medicine.

For the first time I found myself truly caught between my own needs and those of my patient...[After receiving a memo where he learned he was only in 83.1 percent compliance with the measured guidelines,] Because of my financial pressures outside the clinic, I would change my behavior inside the clinic. I had always intended to practice the best medicine possible. The difference is that instead of doing what seems best for the patient, I'll first consider what's best for me. And what's the difference, really? For example, either way a diabetic should have an A1C checked, right?

Mr. Nickels (a pseudonym) was an 84-year-old World War II veteran who had stormed the beach at Normandy....Divorce destroyed his love. The cataracts took away his books. Arthritis left him crippled. Financial ambush took his retirement. And now this likely kidney cancer is the final undignified bullet that will snuff out this soldier's life. There's very little I could do to improve Mr. Nickels' life....Mr. Nickels was so very meticulous that I didn't see the need to check his A1C...

No one who reads the chart will know of my struggle. Not the billing department, not my boss, and I doubt even Mr. Nickels understood the nuances of our interaction. Anyone who reads the chart will see that I was compliant with the established practice guidelines: i.e., I practiced “good medicine." But I know differently—and now you do, too.

Should I start statins on the drooling demented to lower their LDL? Should I preach to paranoid schizophrenics that they must quit smoking? Doing so might help ease my burdens—will it ease theirs? Without a financial incentive, I treated practice guidelines as guidelines, and I treated patients as patients. With financial incentives, will the guidelines become my goal? Will I lose patience for patients who are just a means to my means?

While many doctors are growing increasingly uneasy about the performance measures and risk factor guidelines, recognize that they are faulty and not always clearly supported by clinical research of the utmost integrity, may not reflect the values and preferences of their patients, and worry they may even be harmful for some patients; the insurers have ways of “motivating” compliance even beyond their reimbursements. You know those physician ratings and referral services that list doctors who have demonstrated “excellence” in patient care? Those are based on their compliance with P4P measures, too. So, doctors who don’t comply, risk seeing their financial survival further endangered by bad “ratings” that deter patients away from their practices.

Doctors are being increasingly caught between a rock and a hard place. Few can afford to simply not accept insurance patients in order to get away from these coercions because, in reality, how many people can afford to self-pay? With the financial, paperwork and regulatory pressures on doctors’ practices and all of the hassles, it’s amazing how many keep their doors open. Few would probably put up with it and continue to speak out if they didn’t truly care about people.

Gotta love those who do it for us.

While reasoned, thoughtful critiques of P4P are prolific in the medical literature as doctors speak out about them, “the movement shows little signs of slowing down,” wrote Dr. James Gaulte, M.D. “I hope we are not seeing another instance of ‘the dogs barking and the caravan moving on’ but I am afraid we are.”

©2007 Sandy Szwarc