Paying Physicians for High-Quality Care
http://www.100md.com
《新英格兰医药杂志》
To the Editor: We suggest two additions to the list of challenges facing the innovative "payment-for-performance" initiatives described by Epstein et al. (Jan. 22 issue).1 Current payment-for-performance programs focus on underused services such as retinal and foot examinations for patients with diabetes and the administration of statins for patients with cardiovascular disease, because it is politically awkward to pay doctors a bonus for doing less of something (even if less means better care). To address another large category of quality problems — overuse of nonbeneficial services — different models of "paying for high quality" will need to be designed.
Although physicians with high-quality performance might get bonuses from payment-for-performance programs, they will not necessarily realize higher margins. The staff time needed to review charts, audit data, and deliver the additional services needed (in the case of "underuse," as noted above) means that even if a bonus is earned, the net impact on the margin in a given physician's practice is often neutral or negative.2
These laudable early efforts to channel the attention of physicians to the quality of care are transitional models. Physicians must work with payers and purchasers on payment systems that drive a more comprehensive quality agenda and make a better business case for high-quality physicians.3
Alice G. Gosfield, J.D.
Alice G. Gosfield and Associates
Philadelphia, PA 19103
agosfield@gosfield.com
James L. Reinertsen, M.D.
Institute for Healthcare Improvement
Boston, MA 02215
References
Epstein AM, Lee TH, Hamel MB. Paying physicians for high-quality care. N Engl J Med 2004;350:406-410.
Maguire P. As they struggle to improve quality, HMOs try a new incentive: bonuses. ACP-ASIM Observer. June 2001. (Accessed April 8, 2004, at http://www.acponline.org/journals/news/jun01/bonuses.htm.)
Reinertsen JL, Gosfield AG. Doing well by doing good: improving the business case for quality. June 2003. (Accessed April 8, 2004, at http://www.qualityhealthcare.org/IHI/Topics/Improvement/ImprovementMethods/Literature/DoingwellbydoinggoodImprovingthebusinesscaseforquality.htm.)
To the Editor: Epstein et al. would have us conform to static norms and care for uniform patients, with money as our primary reward. We would prescribe only the "right" drugs, use only the "best" techniques, and implant only the "best" devices, as determined by formularies, pundits, and industry-sponsored studies. With this approach, all postmenopausal women would have been prescribed hormones that are now contraindicated. No patient would be "allergic" to all antihypertensive agents, refuse statins, or prefer aspirin therapy to monthly measurements of the international normalized ratio.
Statistically valid indexes are poor measures of the quality of medical care. Economic incentives are always subject to "gaming," inappropriate manipulation of data, and "cherry-picking" of patients by physicians and groups more interested in making money than in providing good care. Most physicians (and other professionals) work for rewards that are more important than money, including the respect of their patients and peers and the personal satisfaction of a job well done. Medicine is still an art, in spite of basic scientific and health services research. We need better "artists," not more corporate "art critics."
Roy B. Verdery, Ph.D., M.D.
181 Andrieux St.
Sonoma, CA 95476
rbv@drverdery.com
To the Editor: Many practicing primary care physicians have expressed concern about the new National Health Service contract.1 What has been special about primary care in the United Kingdom has been the personal touch and the pleasure of doing things that cannot be counted. The emphasis is now being changed, and one fears the impact that "target oriented medicine" would have on patient care.
If one looks at hypertension as an example, our payment will depend on our providing documentation that a percentage of the patient's blood-pressure measurements are below a defined numerical value. We will have to work out when we will measure blood pressure to coincide with the peak effect of the medications. This approach takes the challenges away from a complex problem when good 24-hour control should be our aim.
No one doubts the value of self-reflection, but when most consultations have a price tag attached to the information that is documented, our role will be trivialized. We will have to work like managers — "milking figures" for targets.
Muttucumarasamy Mahendran, F.R.C.P., M.R.C.G.P.
Milton Keynes Primary Care Trust
Milton Keynes MK8 9EA, United Kingdom
m.mahendran@btinternet.com
References
The NHS Confederation. NEW GMS contract 2003: investing in general practice. London: British Medical Association, February 2003.
To the Editor: The article by Epstein et al. recommends bonus payments to physicians for high-quality care, with the use of a variety of possible strategies. They state that incentives "will put greater direct responsibility on physician practices to `get it right the first time.'" What is not mentioned is the key factor in precluding thoughtful, comprehensive care delivery: the poor compensation for cognitive services that forces practitioners into time-limited efforts. Making ends meet despite rising costs and shrinking revenues is a difficult challenge; the expansion of noncompensated paperwork markedly exacerbates the situation. The multiple plans, formularies, coverage, consultant panels, and involuntary shifting of patients between plans (or to no coverage at all) truly makes our current medical structure the "nonsystem from hell."
What is really needed is a revision of our health care delivery system to achieve a structure that will enhance the opportunity to deliver high-quality care, not diminish it, as is currently the case. In my opinion, a well-done, creative, single-payer system has the best opportunity to accomplish that goal.
Raymond F. Graap, M.D.
5240 E. Knight Drive, Suite 114
Tucson, AZ 85712
rfgraap@earthlink.net
The authors reply: We agree wholeheartedly with Dr. Verdery that most physicians work hard for the respect of their patients and peers and the personal satisfaction of a job well done. In spite of these incentives, however, there is abundant evidence that the quality of care is less than optimal and can be improved. Financial incentives may play a positive role. We recognize that the lack of centralized universal insurance coverage may exacerbate problems with the quality of care, as noted by Dr. Graap. However, even in Canada, which has such coverage, no one has claimed that problems in the quality of care have been eliminated. We doubt that the adoption of a single-payer system will be sufficient by itself to produce the highest quality of care.
Concern about programs that pay for quality, as voiced by Dr. Mahendran, are understandably even greater in England, where the new contract for general practitioners has established incentives for high-quality performance that could determine up to one third of a general practitioner's income. Forthcoming changes in the British health care delivery system may provide valuable insight into the broader costs and benefits of this approach.
Finally, we agree with Ms. Gosfield and Dr. Reinertsen that quality indicators might best include measures of "overuse" as well as "misuse" and "underuse." We expect such indicators to be incorporated in future years. We worry that these writers are correct about the costs of higher-quality care. In some instances, providing better care will cost physician practices additional resources. Unless additional payments for better-quality performance are set sufficiently high that they truly create financial incentives, they are unlikely to be effective.
Arnold M. Epstein, M.D.
Harvard School of Public Health
Boston, MA 02115
Thomas H. Lee, M.D.
Partners Healthcare System
Boston, MA 02199
Mary Beth Hamel, M.D.
Although physicians with high-quality performance might get bonuses from payment-for-performance programs, they will not necessarily realize higher margins. The staff time needed to review charts, audit data, and deliver the additional services needed (in the case of "underuse," as noted above) means that even if a bonus is earned, the net impact on the margin in a given physician's practice is often neutral or negative.2
These laudable early efforts to channel the attention of physicians to the quality of care are transitional models. Physicians must work with payers and purchasers on payment systems that drive a more comprehensive quality agenda and make a better business case for high-quality physicians.3
Alice G. Gosfield, J.D.
Alice G. Gosfield and Associates
Philadelphia, PA 19103
agosfield@gosfield.com
James L. Reinertsen, M.D.
Institute for Healthcare Improvement
Boston, MA 02215
References
Epstein AM, Lee TH, Hamel MB. Paying physicians for high-quality care. N Engl J Med 2004;350:406-410.
Maguire P. As they struggle to improve quality, HMOs try a new incentive: bonuses. ACP-ASIM Observer. June 2001. (Accessed April 8, 2004, at http://www.acponline.org/journals/news/jun01/bonuses.htm.)
Reinertsen JL, Gosfield AG. Doing well by doing good: improving the business case for quality. June 2003. (Accessed April 8, 2004, at http://www.qualityhealthcare.org/IHI/Topics/Improvement/ImprovementMethods/Literature/DoingwellbydoinggoodImprovingthebusinesscaseforquality.htm.)
To the Editor: Epstein et al. would have us conform to static norms and care for uniform patients, with money as our primary reward. We would prescribe only the "right" drugs, use only the "best" techniques, and implant only the "best" devices, as determined by formularies, pundits, and industry-sponsored studies. With this approach, all postmenopausal women would have been prescribed hormones that are now contraindicated. No patient would be "allergic" to all antihypertensive agents, refuse statins, or prefer aspirin therapy to monthly measurements of the international normalized ratio.
Statistically valid indexes are poor measures of the quality of medical care. Economic incentives are always subject to "gaming," inappropriate manipulation of data, and "cherry-picking" of patients by physicians and groups more interested in making money than in providing good care. Most physicians (and other professionals) work for rewards that are more important than money, including the respect of their patients and peers and the personal satisfaction of a job well done. Medicine is still an art, in spite of basic scientific and health services research. We need better "artists," not more corporate "art critics."
Roy B. Verdery, Ph.D., M.D.
181 Andrieux St.
Sonoma, CA 95476
rbv@drverdery.com
To the Editor: Many practicing primary care physicians have expressed concern about the new National Health Service contract.1 What has been special about primary care in the United Kingdom has been the personal touch and the pleasure of doing things that cannot be counted. The emphasis is now being changed, and one fears the impact that "target oriented medicine" would have on patient care.
If one looks at hypertension as an example, our payment will depend on our providing documentation that a percentage of the patient's blood-pressure measurements are below a defined numerical value. We will have to work out when we will measure blood pressure to coincide with the peak effect of the medications. This approach takes the challenges away from a complex problem when good 24-hour control should be our aim.
No one doubts the value of self-reflection, but when most consultations have a price tag attached to the information that is documented, our role will be trivialized. We will have to work like managers — "milking figures" for targets.
Muttucumarasamy Mahendran, F.R.C.P., M.R.C.G.P.
Milton Keynes Primary Care Trust
Milton Keynes MK8 9EA, United Kingdom
m.mahendran@btinternet.com
References
The NHS Confederation. NEW GMS contract 2003: investing in general practice. London: British Medical Association, February 2003.
To the Editor: The article by Epstein et al. recommends bonus payments to physicians for high-quality care, with the use of a variety of possible strategies. They state that incentives "will put greater direct responsibility on physician practices to `get it right the first time.'" What is not mentioned is the key factor in precluding thoughtful, comprehensive care delivery: the poor compensation for cognitive services that forces practitioners into time-limited efforts. Making ends meet despite rising costs and shrinking revenues is a difficult challenge; the expansion of noncompensated paperwork markedly exacerbates the situation. The multiple plans, formularies, coverage, consultant panels, and involuntary shifting of patients between plans (or to no coverage at all) truly makes our current medical structure the "nonsystem from hell."
What is really needed is a revision of our health care delivery system to achieve a structure that will enhance the opportunity to deliver high-quality care, not diminish it, as is currently the case. In my opinion, a well-done, creative, single-payer system has the best opportunity to accomplish that goal.
Raymond F. Graap, M.D.
5240 E. Knight Drive, Suite 114
Tucson, AZ 85712
rfgraap@earthlink.net
The authors reply: We agree wholeheartedly with Dr. Verdery that most physicians work hard for the respect of their patients and peers and the personal satisfaction of a job well done. In spite of these incentives, however, there is abundant evidence that the quality of care is less than optimal and can be improved. Financial incentives may play a positive role. We recognize that the lack of centralized universal insurance coverage may exacerbate problems with the quality of care, as noted by Dr. Graap. However, even in Canada, which has such coverage, no one has claimed that problems in the quality of care have been eliminated. We doubt that the adoption of a single-payer system will be sufficient by itself to produce the highest quality of care.
Concern about programs that pay for quality, as voiced by Dr. Mahendran, are understandably even greater in England, where the new contract for general practitioners has established incentives for high-quality performance that could determine up to one third of a general practitioner's income. Forthcoming changes in the British health care delivery system may provide valuable insight into the broader costs and benefits of this approach.
Finally, we agree with Ms. Gosfield and Dr. Reinertsen that quality indicators might best include measures of "overuse" as well as "misuse" and "underuse." We expect such indicators to be incorporated in future years. We worry that these writers are correct about the costs of higher-quality care. In some instances, providing better care will cost physician practices additional resources. Unless additional payments for better-quality performance are set sufficiently high that they truly create financial incentives, they are unlikely to be effective.
Arnold M. Epstein, M.D.
Harvard School of Public Health
Boston, MA 02115
Thomas H. Lee, M.D.
Partners Healthcare System
Boston, MA 02199
Mary Beth Hamel, M.D.