“The things that people measure in P4P are dictated by ivory tower thinkers. Their relevance to patients, or even to the administrative process, is very questionable,” said Robert Burney, director of Quality Improvement for the U.S. Department of State.
Dr. James questioned the extent to which P4P data has any relevance to patients at all. “The truth is patients really do not use outcomes statistics to make their health care decisions. They rely on stories, based on relationships. They'll tell you they want data, but when we measure decision making, the data do not drive it. We have several good studies of this topic, where they gave patients carefully prepared statistics. Patients say the stats changed their decisions, but when we look closely, people do not change decisions based on data. Humans are more emotional than statistical.”
If patients tend not to respond to data, physicians will … eventually.
Dr. Varga said doctors tend to go through “a sort of 'Kübler-Ross acceptance process'” when it comes to P4P, going from a denial attitude of, “Your data stinks, its all BS,” through one of, “Your data are meaningful but don't really apply to me,” through, “The reason my data are bad is because everyone's data are bad,” to finally accepting there's a need for improvement. But that's provided a P4P system is truly oriented toward system-wide care improvement and not simply punitive toward individuals.
Punitive ranking systems can have a very detrimental effect on health care, said several experts at the conference. On an individual level, P4P may favor older, more experienced practitioners at the expense of younger ones who may have less experience with a given procedure, and thus may get labeled early on in their careers as “lower quality.” This can make it hard for younger doctors to build practices.
There's also a very real danger, said Dr. Varga, of putting smaller rural practices out of business if Medicare reimbursement is overly tied to rigid performance measures. “You can end up destroying health care delivery for small rural counties. A lot of smaller rural hospitals are working on very small margins. If you take away 5% of their Medicare revenue, they close their doors. They can't take that kind of hit.”
At its best, P4P is a set of tools for improving health care outcomes, reducing iatrogenic illness and adverse events, and improving the overall return on every health care dollar spent. Advocates believe that with the right measures, P4P can achieve these goals.
“I think doctors are motivated to improve if they see objective data that they are not performing as well as their peers. It is not necessarily a financial incentive, but a patient care incentive that will motivate them,” said Dr. Jack Lewin, CEO of the American College of Cardiology. ACC has developed a vigorous program of accountability guidelines aimed at improving the quality of cardiovascular care.
“Ultimately, we want to show individual cardiologists how they are doing in relation to their peers on real world indicators, and we want to give them tools for improvement.” Given that cardiovascular disease consumes over 43% of total health care dollars, a little improvement will go a long way, said Dr. Lewin.
ACC is currently studying “door to balloon” time at major centers, in an effort to reduce the interval from when a patient arrives at a hospital until he or she is in the angioplasty suite. “How fast do the best hospitals get you from the e-room door to the balloon angioplasty? You want this to happen within 90 minutes.”
The National Cardiovascular Data Registries, which ACC supports, represent a major national project aimed at tracking hospital performance on a wide range of procedures including immediate response to acute MI, balloon angioplasty, and implantation of defibrillators. Data are being gathered in roughly 2,300 centers around the country.
“We can tell the medical staff how they are doing compared to their peers,” Dr. Lewin said at the conference, which was sponsored by the Wall Street Journal and CNBC. “We still need the patient outcomes side, but the program is underway, and some states mandate that hospitals participate if they want the states' Medicare and Medicaid data.”
Dr. Peter Angood, codirector of the Joint Commission International's Center for Patient Safety, likened current quality improvement efforts, flawed though they may be, to the airline industry's efforts to improve safety performance.
“It took the aviation industry 40-45 years to improve performance quality and really get continuous quality improvement in place. In health care, we're just passing the stage where we acknowledge there's a problem. How do we compress that 40-year curve down to just one generation?” Dr. Angood asked.