Health Reform and Grassroots Realities: Pay for Whose Performance? Physicians or Patients?

Yesterday I received a robo call from a doctor. The call said, in essence, show up for your visit, or we will dun you $50.

No-Shows

This call may sound harsh, but the grassroots reality is that the number #1 pet peeve of doctors is so called “no shows, “patients who do not show up for their appointments. “No shows” comprise about 20% of office visits. Even when the patient “shows”and is referred to a specialist for a suspicious symptom, only about 50% make their scheduled specialty appointments. And when given prescriptions, roughly 30% of patients did not fill them, sometimes because they cannot afford to.

Object Lesson

The object lesson is that physicians cannot control patient behavior nor do patients necessarily follow orders. The problem intensifies in bad economic times. There is not much doctors can do about “no shows,” except overbook, make calls reminding patients of their appointments, or resort to automated calls threatening economic retribution.

Grassroots Realities

The grassroots realities are that America is a free country; patients can do what they want to do. We are also a complex country. This complexity makes health reform difficult, as I noted in my book Obama, Doctors, and Health Reform, with this observation “American health care is a whirling Rubik’s Cube, with millions of interrelated moving parts, institutions, and people.”

Which brings me to a piece in today’s New York Times, “Paying Doctors for Patient Performance.” A movement is afoot among private and public health plans to pay doctors for performance. This so-called P4P movement is based on the notion that good doctors will meet certain goals – their patients will show up for mammograms, Pap smears, colon exams, and cholesterol checks.

Predictable Results

Alas, however, and predictably, the nature of the patient population served has more to do with reaching these goals than the quality of doctors delivering the care. In a Massachusetts General study of 125,000 patient visits to 162 primary care physicians to five hospitals run by a single academic institution, the authors concluded “Patient panels with a greater proportion of uninsured, minority, and non-English speaking patients were associated with a lower quality rating for primary care physicians (Hong, C., et al,”Relationship between Patient Panel Characteristics and Primary Care Performance,” JAMA, September 8, 2010).

Conclusions

The authors of the JAMA study conclude. “We need more sophisticated measures to make sure we are actually measuring physician quality.” How much more “sophisticated” is unanswered. The authors used an EHR linking 162 primary care physicians. That sounds pretty sophisticated to me.

Perhaps I am “unsophisticated,” but I conclude differently. No matter how much data you assemble and how you parse it, you cannot separate high performance physicians from badly performing physicians. In the end, physician performance depends on patient performance as well. You cannot separate physician performance from patient performance. External events, patient socioeconomic status, ability to pay, and the status of the economy, can make a significant difference.