Moreover, when he restricted his analysis to just groups termed "high-incentive" groups, there was still no more improvement than controls. High-incentive groups were defined as ones that could receive performance bonuses of $100,000 or more, or for whom individual primary care physicians could receive bonuses of more than $1,000.
There are two plausible explanations for the findings, Dr. Pearson said. "Either P4P has worked in Massachusetts because it is part of this atmosphere of driving quality improvement … or P4P has failed because it is either too weaknot enough money on the tableor it was poorly designed."
Fragmented Care Poses Dilemma For P4P System
Pay-for-performance schemes may be thwarted by patients seeing too many doctors, making it difficult to assign any one patient's care to a particular physician, according to a study that was presented at the annual research meeting of AcademyHealth.
The average Medicare patient sees seven physicians (two primary care, five specialists) over a 2-year period, Dr. Hoangmai Pham, a senior researcher with the Center for Studying Health System Change, Washington, said at the meeting.
Dr. Pham analyzed data from Medicare sources that included claims data and nationwide physician surveys for 20002003. Only 53% of Medicare beneficiaries' evaluation and management visits, and 35% of their total visits, are with the physician identified as their primary, or usual-source-of-care, physician.
During a 2-year period, 30% of beneficiaries switch their usual-source-of-care physician, and in 59% of the cases where beneficiaries switch, they never even see one of the designated physicians in a year, Dr. Pham said.
According to the physician survey data, a primary care physician's regular, usual-source-of-care patients make up an average of only 39% of his or her total patient population.
In today's medical environment, it takes more than one doctor to care for a patient, Dr. Pham said.
The Department of Health and Human Services has committed the Medicare program to advancing the concept of pay for performance, Dr. Pham noted. But what is really needed is an overhaul of the medical system to allow single physicians or groups to be responsible for individual patients. Alternatively, more financial incentive in pay for performance would make it worthwhile to invest in the infrastructure physicians need to participate, because they will be able to show good performance for only a small proportion of their patients, she added.