Friday, August 3, 2007


Many bloggers have weighed in on P4P. For the non-medicals out there, P4P stands for Pay for Performance. In a nutshell, Medicare and a number of private insurers want to set some concrete numbers as benchmarks of a "good" physician, and pay them a bit of a bonus.

Sounds like a pretty good idea, huh?

Well, like most completely horrible ideas, on the surface this doesn't sound so bad.

There are SO many reasons why this is a bad idea. I don't have the organizational skills to go through them all today (TGIF), but it's been done elsewhere, and quite well.

There's one reason that's bugging me today.

P4P will make healthcare for the disenfranchised even worse.

We doctors call them "noncompliant". That's the medical buzzword for "lazy, won't listen, doesn't care" and it's fairly accurate. Now, there's a movement (especially in the public health center world) to stop using that word. Apparently it's got a negative connotation, and supports a paternalistic model where doctors TELL patients what to do.

I think that's a steaming load of hooey. You make a well-established evidence-based recommendation. Patient doesn't follow it. Noncompliant.

But that doesn't mean that patient gets thrown out with the trash.

There are lots of reasons for noncompliance. Lack of education. Lack of support. Lack of trust. Lack of role models. Lack of funds. Lack of transportation. Lack of giving a crap. Too many other things to worry about. Too many other family members to care for.

Part of the job of a doctor is to try to identify any modifiable issues and fix them. Another part of the job of a doctor is to continue to take care of people who won't take care of themselves.

Enter P4P.

Every poorly controlled diabetic I have decreases my chances of getting a bonus. Every missed or refused flu shot. Every declined mammogram.

Remember Ross Perot's "giant sucking sound"? I anticipate a deafening thud, as these patients, already doing poorly, are dropped like lead weights off of a sinking ship.

P4P will penalize the doctors who take the extra time and effort it takes to care for the noncompliant patient (not to mention the increased medicolegal risk).

But more importantly, P4P will remove the chance of getting any semblance of adequate health care. No one will want them.


TBTAM said...

It's just one more ruse to make us do more work to get paid for what we do....

Camiseta Personalizada said...
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