P4P - 2

The question posed earlier this week asked how doctors felt about having their clinical practices — the tests they must do, the clinical guidelines they must follow for everyone, the prescriptions they must write, and the reporting and billing they must do — determined by the government and third party interests. Those determinations are called “pay-for-performance” measures. P4P are used to determine the compensation doctors receive from insurers, including for Medicare and Medicaid, with rewards and penalties to impel compliance.

Dr. James Gaulte at MDredux gave the answer today.

They don’t like it one bit.

This won’t be at all surprising to most medical professionals, but may be of help for lay readers in better understanding the oppositions and concerns among doctors over third-party or government-run healthcare systems. In a strong article titled “Total responsibility to our patients,” he added his voice to doctors saying that their responsibilities are to their patients, not to systems. There is a crisis in medicine today, he said, as the single payer system influences more than fees. It endangers the very fiduciary duty of doctors to their patients, as bureaucrats come between patients and their doctors. However, it’s not just from the dominating control of third party payers, he writes, but from:

... the self destructive rhetoric of many of the professional organizations and academics who strongly influence the emerging generation of physicians. A glaring example is the “new professionalism" as pushed forward by ...many other professional organizations- which ... seems to equal professionalism with the imperative to meet the third party payers in their effort to improve “quality and efficiency." See if you can find a general internist in private practice who believes that the third party payer are interested in real quality.

Physicians take care of their patients and are responsible for them. Systems do what systems do and cannot care or be responsible for individuals....

Dr. Gaulte then turns our attention to Dr. Richard N. Fogoros at Covert Rationing who discusses the reality of all such systems: there will always be shortages and efforts to control costs (or make money for the system or those in control), resulting in disparities that give greater access to the rich, the connected or clever. As he writes:

The twist is: We’re Americans, and Americans don’t ration. So the central authorities who control the American healthcare system have got to do the rationing covertly.... Covert rationing corrupts everything it touches...Whatever pockets of excellence you get will have to be created by a few special individuals who are unusually self-motivated.

These reverse [P4P] incentives, we’ve seen, are aimed at actively stamping out, eradicating, and punishing any self-motivated physician who tries, despite all obstacles, to deliver excellent healthcare. Among these are the mandate that primary care doctors spend only 7.5 minutes per patient encounter; invoking the magic of P4P to determine exactly what must and must not take place during that 7.5 minutes; grabbing the right to interpret clinical science in order to formulate the “guidelines” that inform P4P; coercing doctors to agree to egregious adhesion contracts that any sane person would find unconscionable; forcing doctors to practice under a set of coding “guidelines” that prevent good patient care and serve as traps for “fraud;” and in general, making every patient encounter subject to a web of regulatory speed traps that force doctors to concentrate on keeping the OIG (Office of Inspector General) at bay rather than on what the patient needs. In short, in their efforts to gain control of physicians’ behavior in order to covertly ration healthcare, American Wonkonians re-creating insurmountable, systematic disincentives for excellence and penalties for non-mediocrity. They have placed doctors in the untenable position of being utterly unable to fulfill their professional, traditional, legal, and ethical obligations.

Whew. Food for thought.