Friday, March 30, 2007

Doctor Patient Relationships - Pay for Whose Performance

Buzz, Metrics, Outcomes. and Human Nature

This originally appeared HealthLeaders News, Mar. 16, 2007

As an occasional contrarian, I sometimes question accepted wisdom. One piece of dogma I hear repeatedly is that physicians should be held directly responsible and strictly accountable for patient outcomes and should be paid accordingly. That’s the essence of arguments for pay-for-performance programs.

Below, I raise these three questions:

1. Should physicians be paid extra for performance by “administrative pricing regulators” when physicians are professionally obligated to do the right thing in the first place in the best interests of patients?
2. Will P4P in all its complexities and unforeseen consequences slow growth of healthcare spending?
3. Should P4P programs be extended beyond the hospital to outpatient settings?

Contagious Buzz

Accepted wisdom is contagious. Hang around hospital and health plan executives long enough, and you will hear a lot of buzz about quality.

The buzz goes like this:

• “Quality and metrics are where it’s at.”
• “All we need to do is to get our arms around the metrics.”
• “If only we could get clinicians to behave and follow measurable quality indicators.”
• “Pay for performance is the wave of the future, if only doctors would climb on the bandwagon.”
• “Manage doctors, and you manage quality.”

Metrics conflicts

The buzz on the doctor side of the aisle may differ. Some doctors are openly skeptical about the value of P4P. Why are some doctors dubious about measuring outcomes and being paid for them?

From the doctor standpoint, there may be several reasons, as evidenced by the Winter issue of the Minnesota Quality Review report, which contains a number of provocative articles.1

Here are some of their titles:

• “Paying for Performance: Physicians Support It But Want It Tweaked, Tested, and Watched Closely.”
• “Not Really What the Doctor Ordered.”
• “Is Everything Negotiable: Physicians Find They Often Have Some Leeway to Negotiate Pay-for- Performance Goals with Health Plans.”
• “Pay for Whose Performance? Minnesota Clinics Carve Up the Bonus Pie in Different Ways.”

I take these articles seriously. As former editor of Minnesota Medicine and a lifelong student of healthcare in Minnesota, I know Minnesota physicians, who tend to congregate into large well-managed groups, are scrupulously dedicated to quality.

Serious Questions

Yet Minnesota doctors question whether:

• Quality measurements are for the benefit of hospitals and health plans rather than for doctors and patients. In other words, pay for whose performance? P4P, I find, is not really what most doctors would order to judge their own performance.
• P4P bonuses for doctors, typically in the 3 percent range, are a sufficient incentive to pay for installing expensive electronic health systems to record doctor-entered quality indicators, which are necessary to track outcomes.
• They should have more leeway in negotiating P4P goals with health plans and in setting realistic standards.
• P4P programs are really effective in improving quality and may be at the tipping point.
• Current evidence of P4P justifies them being applied nationally.2,3
• Health plans and hospitals realize patients are often more responsible for disease outcomes than doctors themselves.

Thin Evidence of P4P Effectiveness

Why is the increase in quality and outcomes only marginally effective with P4P programs? After all, it is intuitively compelling that a broad base of evidence aligning outcomes with bonuses would work. However, the evidence is thin indeed that P4P actually works.4,5

What’s going on here? Is it because:

• Doctors aren’t concerned about quality?
• Demands in costs and efforts in money, training, staff time in installing systems and entering and tracking data are excessive?
• Doctors are technophobic?
• Sixty percent of doctors are in practices of four or less and simply lack the IT infrastructure to track P4P?
• Patients fail to change behavior and don’t comply with instructions once out of the reach of doctors and hospitals?

Doctors and Bad Outcomes

Politically and intuitively, it’s easy to blame doctors for bad outcomes. Doctors are the authority figures. Doctors write the prescriptions, treat the patients and control the money flow. You often hear the truism doctors generate or control 80 percent of money expended in the system, although I have yet to meet a doctor who believes this.

It would also seem to make intuitive sense that improving “processes of care” in the outpatient environment would improve outcomes. But this may not be so. The Health Disparities Collaboratives of the Health Resources and Services Administration recently performed a controlled preintervention and postintervention study of 9,658 patients with diabetes, asthma and hypertension participating in community health centers quality improvement program.6

The conclusions? “The Health Disparities Collaborative significantly improve the processes of care for two of the three conditions studied. There was no improvement in the clinical outcomes studied.”

No mention was made of the patient behavioral factor, merely that “the substantial room for improvement in the postintervention period suggests the need for continued refinement of these methods.”

In judging outcomes, it’s much harder to measure noncompliance and unhealthy behavior of patients outside traditional care settings. Besides, patients are supposedly at the mercy of the doctors and are most vulnerable to high health costs.
Can you imagine a health plan or Medicare official saying, “Patients are equally responsible for bad disease outcomes”?

I can’t. That would be politically incorrect, certainly insensitive and maybe even scandalous.

Human Nature and the Declaration of Independence

There are other factors as well–human nature and independent patients with their own minds. As John Naisbitt points out in Mind Set! (Collins, 2007), the U.S has an “overwhelming bottom-up society.” Americans believe in individualism and freedom, and patients tend to behave the way they want to behave and change behavior and old habits only reluctantly.

As an example, 40 percent of type 2 diabetics at risk ignore doctors’ advice to be active. And the more in danger patients are, the less likely they are to be inactive.7

A Smoking Gun

I vividly remember a photograph of John Johnson, a West Virginia coal miner, on the front page of the New York Times (Eckholm, Eric, “Medicaid Prods Patients Towards Health,” December 1, 2006).

Johnson, 61, had lost a leg to diabetes and was smoking a cigarette in the Times photo. When doctors urged him to change his diet and to stop smoking to qualify for better Medicaid benefits, Johnson said, “I told them I eat what I want to eat, and the hell with them. I’ve been smoking for 50 years–why should I stop now?”

Self-evident Truths

Other self-evident truths exist as well. Here are five:

1. People spend 99.9 percent of their time outside of doctors’ offices and hospitals. This time gap is particularly important in patients with chronic disease. Your outcomes depend on how and where you live and work. The system recognizes this. It is decentralizing and moving chronic care management to homes and worksites. Internet and nurse monitoring may help close monitoring disease gaps. But gaps in care--gaps beyond the physician’s control--still loom large. Insurance coverage may or may not be important in outcomes. According to Amy Finkelstein of MIT, Medicare had no effect in reducing elderly mortality in its first 10 years of existence (“The Cost of Coverage: The Sobering Lessons of Medicare,” Wall Street Journal, February 28, 2007.)

2. Many patients don’t follow doctors’ orders. Many never fill prescriptions, fail to get refills and avoid exercise. The lack of prescription compliance has led to a boom in physician office dispensing, the rationale being that patients are more likely to follow instructions when the doctor directly hands them the prescription, looks them in the eye and tells them to follow orders. And it’s no secret that fitness centers are a great business because of the high recidivism rate of subscribers to these centers (more than 50 percent drop out).

3. Many people dig their graves with their own teeth, hence, the obesity epidemic, which has now reached worldwide proportions.8 That’s why obesity is replacing smoking as the poster child for preventing chronic disease, and health plans will be paying members to join Weight Watchers and similar organizations.9

4. Half-way technologies–stents, coronary bypasses, joint replacements, statins, etc.–don’t eliminate underlying diseases or change their basic pathophysiology. The problem here, of course, is many patients have overblown expectations at what these technologies will accomplish and often return to the behavior that led to the problem in the first place.

5. Modern technologies--cars, home computers, video-games, TVs, etc.–confine movement and foster obesity. These technologies are part of the culture and are beyond the physician’s influence. Add to these technologies junk food, transfats, absence of suburban sidewalks, lack to time to exercise, and you compound the outcome problem. To paraphrase James Carville, when it comes to obesity outcomes, “It’s the culture, Stupid!”

Doctors aren’t Blameless

Doctors aren’t blameless for poor outcomes or for failing to follow guidelines. It’s well-documented doctors only follow preventive and treatment guidelines 50 percent to 55 percent of the time. Moreover, doctors could do a much better job communicating with and educating patients, deploying the Internet (for example) to reach patients when they are outside of the immediate care setting.

Doctor-patient education outside the office is beginning to take off. Two examples spring to mind:

1. Emmi Solutions, founded in 2002 by a Chicago urologist, David Sobel. The company provides online interactive programs of what to expect from surgical procedures and chronic disease episodes and gives them to patients and their families to view at their leisure at home.

2. EDocAmerica, founded in 1998, by Charles Smith, a family physician and medical director at the University of Arkansas medical center in Little Rock. His company, staffed by 12 national family physician leaders, uses the Internet and email to “prescribe” healthcare information for employees of large groups about their health care options.

Compelling doctors to follow guidelines and enforcing their compliance is not as easy as it might seem. Whose guidelines? Keep in mind there are more than 2,000 guidelines floating around out there. You may find them at the National Guideline Clearinghouse website ( These guidelines depend on both evidence and opinion and are neither infallible nor a substitute for clinical judgment.

Doctors are mortal and may have a hard time keeping all these guidelines in mind. Small wonder that adherence to guidelines and outcomes vary. As I outline above, patient behavior outside of the office and hospital settings is an important factor in healthcare outcomes. Doctors can’t be held solely--or even primarily--responsible for outcomes, and rewarding or punishing them for outcomes may be overly simplistic.

Doing so in the confined hospital setting may make P4P advocates “feel good,” and it is a good place to start, but P4P may not lead to better long-term outcomes.
Quality, outcomes and metrics to measure the relationships among these three are very much the buzz these days, especially in hospital, health plan and Medicare circles. Often the blame for poor outcomes falls on doctors.

What this buzz fails to address adequately is failure of patients to comply with doctors’ instructions and to change unhealthy behavior when out of the doctor’s immediate sphere of influence.

Perhaps Rodney Hayward, M.D., from the VA Ann Arbor Health Services Research and Development Center of Excellence and Schools of Medicine and Health at the University of Michigan, says it best: “The last thing we need is a performance-measurement system that encourages a little improvement in quality and a substantial increase in costs.... The value and importance of most medical treatments vary tremendously among patient populations in complex ways.... Until our performance-measurement system is based on clinically relevant information and targets high-priority care, performance measurement is likely to remain a great idea that is more of a distraction than a benefit.”10

A Few Final Points

--P4P may be “fundamentally a social experiment likely to have only modest incremental value.”3
• P4P is an experiment worth conducting in hospitals.
• The closed hospital environment is a good place to start because it addresses high priority clinical problems.
• Doctors in hospital practice should follow existing quality indicators.
• P4P in outpatient settings will be hard to implement and is unlikely to improve outcomes.
• Berating physicians for high costs and poor outcomes is a counterproductive strategy.
• Rewarding physicians for what they are professionally obligated to do in the first place may be an unrewarding and counterproductive strategy.
• Resistance to behavior change among patients is significant and makes long-term P4P measurable outcome improvement unlikely.
• Outcomes depend heavily on cultural factors.
• Resources devoted to prevention and wellness are more likely to be effective in improving outcomes than P4P.


1. MMA Quality Review: “Physicians in Pursuit of Excellence,” Winter, 2007.
2. Lindenauer, P., Remus, D., Roman, S., Rothberg, M., Benjamin, E., Ma, A., and Bratzler, D., “Public Reporting and Pay for Performance in Hospital Quality Improvement,” New England Journal of Medicine, volume 356, pages, 486-496, 2007.
3. Epstein, A., “Pay for Performance at the Tipping Point,” New England Journal of Medicine, volume 365, pages 515-517, 2007.
4. Rosenthal, M., and Frank, R., “What is the Empirical Basis for Paying for Quality in Health Care,” Med Care Res Rev, 63:135-157, 2006.
5. Peterson, L., Woodard, L., Urech, T., Daw, C., and Sookanan, S., “Does Pay-for-Performance Improve the Quality of Health Care?” Ann Intern Med, 145: 265-272, 2006.
6. Landon, B., Hicks, L., O’Malley, A., Lieu, T., Keegan, T., McNeil, Barbarad, and Guadagnoli, E., “Improving the Management of Chronic Disease at Community Health Centers,” New England Journal of Medicine, volumes 359, pages 921-934, 2007, March 1.
7. Squires, C., “Study: Most Diabetics Don’t Exercise,” Associated Press, January 26, 2007.
8. Hossain, P., Kowr, B., and El Nahas, M., “Obesity and Diabetes in the Developing World,” New England Journal of Medicine, 356:313-315, 2007.
9. Spector, H., “Insurer to Pay for Weight-Loss Efforts,” Cleveland Plain Dealer, February 1, 2007.
10. Haward, R.A., “Performance Measurement in Search of Path,” New England Journal of Medicine, 356:951-954, 2007, March 1.