UNITING PHYSICIANS & PATIENTS AS A VOICE IN HEALTH CARE
(1) Paul M. Ellwood, Jr., "Health maintenance strategy," Medical Care 19719:291-298. This paper is based on a paper Ellwood wrote in 1970 for the Nixon administration explaining his theory that pushing Americans into HMOs would reduce health care costs.
(2) Markian Hawryluk, "Medicare experiments with quality incentive programs," American Medical News, November 4, 2002, 7.
(3) Integrated Health Care Association statement, http://www.iha.org, accessed December 17, 2003.
(4) Dan McLaughlin and Brian Campion, "Pay for performance," Minnesota Physician, October 2003, 1; Douglas Hiza, "BCBSM launches provider incentive programs," Minnesota Physician, October 2003, 11.
(5) For example, Paul R. Reich, MD, the medical director of Blue Cross and Blue Shield of Rhode Island recently wrote an article entitled "Pay for performance" in which he stated, "With the decline of capitation as a means of compensating doctors, 'paying for performance' has become a viable alternative." Because capitation payments reduce utilization and have not been shown to improve quality, it is reasonable to infer from Dr. Reich's statement that he defines "pay for performance" to mean "paying for reduced utilization." Dr. Reich confirmed the accuracy of this inference later in the article when he said, "[I]f the goals [of the pay-for-performance program] comprise too many decreased-utilization targets, some may view the plan as asking physicians to reduce the amount of care provided to members to enrich themselves" (Paul R. Reich, "Paying for performance," Managed Care Interface 2003;16:14). Clearly, Blue Cross and Blue Shield of Rhode Island defines "pay for performance" to mean both "pay for quality improvement" and "pay for utilization reduction."
A recent article in Minnesota Physician offers another example of the misuse of phrases similar to "pay for performance." Douglas Hiza, MD, the medical director for Blue Cross and Blue Shield of Minnesota (BCBSM), wrote that BCBSM "recently launched two new outcomes-based provider incentive programs," one of which was dubbed "Recognizing Excellence." He went on to say the purpose of these programs was "rewarding provider performance relative to proven clinical outcomes." These phrases would lead anyone to think BCBSM perceives "pay for performance" to mean improving quality only. But Dr. Hiza then noted that the programs included "a goal of increasing appropriate use of generic drugs" (Douglas Hiza, "BCBSM launches provider incentive programs," Minnesota Physician, October 2003, 11). Increasing the use of generic drugs is clearly a cost-containment goal, not a quality-improvement goal. There is no evidence that generic drugs are as a class more effective than brand-name drugs.
(6) "Governor announces citizens forum on health care," press release, September 8, 2003, Office of Governor Tim Pawlenty, http://www.governor.state.mn.us/Tpaw_View_Article.asp?artid=543, accessed December 17, 2003.
(7) A search of Medline using the phrase "pay for performance" turned up 42 articles published since 1979. Half of these were published after 1997. None presented evidence that PFP, as defined in this paper, improved quality of care or reduced costs.
(8) Edward L. Hannan et al., "Improving the outcomes of coronary artery bypass surgery in New York State," Journal of the American Medical Association 1994;271:761-766.
(9) Jinnet B. Fowles et al, "Taking health status into account when setting capitation rates: A comparison of risk-adjustment methods," Journal of the American Medical Association, 1996;276:1316-1321, 1317.
(10) Timothy P. Hofer et al., "The unreliability of individual physician 'report cards' for assessing the costs and quality of care of a chronic disease," Journal of the American Medical Association 1999;281:2098-2105, 2101.
(11) Yujing Shen, "Selection incentives in a performance-based contracting system," Health Services Research 2003;38:535-552.
(12) Jesse Green and Neil Wintfeld, "Report cards on cardiac surgeons: Assessing New York State's approach," New England Journal of Medicine 1995;332:1229-1232.
(13) The study sample included 3,642 diabetic patients seen by 232 physicians. This averages out to 16 patients per physician. However, the actual number of diabetics seen by the 232 physicians was one-third higher because a third of these physicians' diabetic patients were excluded from the sample, either because they declined a telephone request to participate in the study or because they failed to return a questionnaire used to risk-adjust the scores.
(14) Hofer et al. op cit., 2098.
(15) Ibid, 2104.
(16) Linda O. Prager, "Cleveland Clinic's withdrawal dooms decade-old report card project," American Medical News, April 12, 1999, 9.
(17) Franks et al. reported that patient income affects health care utilization even within a sample restricted to patients with private insurance. Lower-income patients were less likely to get Pap smears, mammograms, and diabetic eye exams, were less likely to make an office visit, and were more likely to be hospitalized and generate more expenditures for tests (Peter Franks et al., "Effects of patient and physician practice socioeconomic status on the health care of privately insured managed care patients," Medical Care 2003;41:842-852).
(18) "In fact, several studies estimate that only 15 to 20 percent of medical practices can be justified on the basis of rigorous scientific data establishing their effectiveness. For most conditions, something other than rigorous data on efficacy or effectiveness must be used to determine criteria of appropriateness" (Paul G. Shekelle et al., "The reproducibility of a method to identify the overuse and underuse of medical procedures," New England Journal of Medicine 1998;338:1888-1895, 1888).
(19) Bruce E. Landon et al., "Physician clinical performance assessment," Journal of the American Medical Association 2003;290:1183-1189.
(20) See for example, R.A. Hoff et al., "Mental illness as a predictor of satisfaction with inpatient care at Veteran Affairs hospitals," Psychiatric Services 1999;49:929-934.
(21) Mark J. Edlund et al., "Does satisfaction reflect the technical quality of mental health care?" Health Services Research 2003;38:631-645, 631,
(22) Donald M. Berwick, "The toxicity of pay for performance," Quality Management in Health Care, 1995;4:27-33.
(23) Landon et al., op cit., 1188.
(24) Hofer et al., op cit. The study Hofer et al. cited was E. J. Orav et al., "Issues of variability and bias affecting multisite measurement of quality of care," Medical Care 1996;34 (supplement 9):SS87-SS101.