UNITING PHYSICIANS & PATIENTS AS A VOICE IN HEALTH CARE
For three reasons, the Forum should not recommend PFP as a cost-containment method. First, assuming that PFP can improve quality, it is not clear that quality improvement always leads to cost reduction. Second, it is not at all clear that PFP can improve quality. Third, putting PFP on the front burner when more pressing quality and cost problems remain unsolved (managed care, the nursing shortage, and the absence of universal insurance are among them) does not make sense, but if it must be on any burner, then research should be done first on how accurate report cards on doctors can be and what they will cost in both dollars and lost privacy. PFP should not be implemented until these questions about PFP's cost and accuracy have been answered. Inaccurate report cards are a disservice to both doctors and patients.
This paper has focused on only some of the impediments to and problems associated with PFP. For a discussion of other problems, we refer readers to the previously cited papers by Hofer et al and Landon et al., as well as a paper with the unequivocal title, "The toxicity of pay for performance." (22)
The primary obstacle outcome-based report cards must overcome is the difficulty of accurate risk adjustment. Accurate risk adjustment is expensive and requires either time-consuming collection of patient consent or routine violation of patient privacy. But even sophisticated, expensive risk adjustment may be unable to eliminate the incentive for physicians to game the system – to overstate risk factors and to jettison sick patients.
The primary problem with process measures is that they require consensus on standards of care, and such consensus does not now exist for the great majority of medical services. Moreover, some process measures must be risk adjusted.
Finally, "consumer satisfaction" surveys are not a short cut to accurate report cards. They too must be risk adjusted. Moreover, the typical survey-based report card needs to be unbundled so that readers (including the doctors who presumably will attempt to alter their behavior upon reading the report card) can understand which type of service respondents had in mind when they answered the survey questions.
We agree with this statement by Landon et al.: "At the current time, given the state of technology and the existing infrastructure to support performance assessment, broad-based mandatory clinical performance assessment for individual physicians as a means of determining the competence of individuals physicians . . . appears to be infeasible." (23) It appears now that only a few simple process measures can serve as the basis for PFP schemes, and that sufficiently accurate outcome and process measures for the vast majority of other medical services will probably never materialize, and those that do will be expensive to prepare.
Perhaps the most startling finding by the few investigators who have attempted to investigate the accuracy of report cards and the usefulness of PFP schemes is that variations in physician practice style account for a very small proportion of the variance. Hofer et al. reported that physicians accounted for only 3 percent of the variation in HbA1c levels, and they cited another study which found that "the practitioner accounted for a maximum of about 24 percent of the variance in a process-of-care score related to the management of digoxin and a minimum of 3 percent in process scores related to cancer screening." (24) It is difficult to conceive of a more fundamental question than, Are these estimates correct, and are they representative of all medical services?
If more research confirms that physician practice style accounts for a small percentage of the variation in quality for most medical services, we could then state with confidence that it is irrational to focus on physician behavior as a means of improving quality when patient behavior and other factors outside physician control account for the vast majority of the variation in quality. Because managed-care plans now have considerable control over physicians and much less control over patients and the factors that affect patient care-seeking behavior (such as education and availability of child care), it is no doubt tempting to managed care officials and their allies in the health policy community to focus on physician behavior. But, if the physician effect on variation in quality is in fact small, the strategy of focusing on doctors may be compared to the strategy of the drunk who lost his keys, he knows not where, but he persists in restricting his search to a small area under a street light because that is where the light is good. Before the Forum spends any time debating PFP, the Forum should resolve first the question of whether physician practice style explains a substantial portion of the variation in report card scores.
Managed care advocates and health policy experts, some of whom sit on the Forum, endorse evidence-based medicine. MPPA likewise endorses evidence-based medicine. However, what is good for physicians is also good for health policy experts and managed-care advocates. MPPA endorses evidence-based health policy as well as evidence-based medicine. There is, at this date, no convincing evidence that PFP schemes will improve quality or reduce costs, and some convincing evidence that they will damage quality. We urge the Forum to adopt evidence-based health policy, and to refrain from endorsing PFP, either as a method of improving quality or of reducing cost.