But, for five measures—chlamydia testing, hemoglobin A1c testing in diabetics, LDL cholesterol testing in diabetics, urine testing in diabetics, and well-child visits by adolescents—the control groups had more improvement. And, two of the four measures for which the contract groups outperformed the control groups were dominated by a special contract and a single 38-physician practice, Dr. Pearson said.
Moreover, when he restricted his analysis to just groups termed “high-incentive” groups, there was still no more improvement than in 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 weak—not enough money on the table—or it was poorly designed.”
Money indeed may turn out to be the pressing issue as pay for performance becomes more common.
Slowly but surely, many physicians seem to be coming around to pay for performance because they see it as an effort in medicine to make quality a priority, these investigators said.
But Dr. Damberg said California groups have told her they want help recouping their investments. If it doesn't come, she is afraid they will lose patience. “It is really still too early to declare victory or defeat for pay for performance,” Dr. Damberg concluded.
Ignoring pay for performance won't make it go away, said Dr. Howard B. Beckman, medical director of the Rochester IPA. Timothy F. Kirn/Elsevier Global Medical News
Fragmented Care Undermines P4P
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 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 a number of Medicare sources to come to her conclusion. These sources included claims data and nationwide physician surveys for 2000–2003.
Not only do patients see a number of physicians, but their main physician may not even see them the majority of the time; they also switch their primary provider often.
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.
What is really needed is an overhaul of the way the medical system is organized to allow single physicians or groups to be responsible for individual patients.
Alternatively, there needs to be more financial incentive in pay for performance to make it worthwhile for physicians to invest in the infrastructure needed to participate, because they are going to be able to show good performance for only a small proportion of their patients, she added.