In its infinite wisdom (NOT), the government’s bean counters have decided that they need a new way to shave more expenses out of Medicare. The grand plan is to continue to reduce reimbursements to physicians and academic institutions, while at the same time finding new ways to divert more money to insurance companies (Medicare “Advantage”), pharmaceutical companies (part “D”), and big business companies (retail “clinics”).

To attempt to make this seem palatable to physicians, CMS and Congress have invented the Pay for Performance (P4P) program, that will offer to physicians a small “bonus” payment if they spend all year jumping through hoops to prove that they know how to practice medicine. Not by keeping their patients out of the hospital or saving someone’s life, but by correctly tracking, collecting, and submitting dozens of brand-new code numbers.

This is obviously just throwing a small bone the physicians’ way, because they count on Dr. Average not having the wherewithal to submit enough numbers to qualify for any reward money. Sounds like the game invented by the third party payors when they noticed that it was to their advantage to initially deny claims, even when they knew they were valid, because so few physicians noticed and resubmitted them.

Dr. Whited gives his take on the pros and cons of this plan in the letter he wrote to MD Net Guide which is available for viewing in Second Opinion and in the full post.

Hopefully this will get some discussion going ;-)

Philip A. Gilly, MD, FAAFP
Family Physician, computer enthusiast, digital photographer, Webmaster and Internet content creator.

Philip owns and operates a low-overhead solo private practice, the Kinderhook Wellness Center. Maintains the Kinderhook Connection Web portal, which provides Web content services for a local medical office, medical society, bookstore, and business association, as well as news and information about the historic village of Kinderhook, NY. As for the print media, he has been published in two medical journals, has had numerous articles published in local newspapers on medical issues, and serves as a reviewer for Family Practice Management.

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SECOND OPINION

The news items and articles on pay for performance (P4P) we have included in recent issues of the mdng.com magazine and in our eDigests have generated some interesting responses from our readers, one of whom wrote to convey his thoughts on EHRs and P4P(April 2007)

To P4P or Not to P4P…

You might he interested in some of my recent experiences with an EHR and how it affects the doctor patient relationship. As a solo family practitioner with no EHR, I have already begun to see patients who tell me the reason for leaving their last MD was that “he spent the entire visit looking at the computer!” I am sure I have lost patients who will complain to their new physicians that “Dr. Whited is just too low tech!”

My practice is totally devoted to interacting one on one, face to face with the patient and I do not intend to change. If I am ever forced to use a computer as a medical record, I will wait to enter data until after the patient visit is over to avoid losing my focus on the other human being involved in the interaction. I feel I will always (at least for the next decade until I die or retire) have plenty of patients interested in a physician who is interested in them as a person and not as data on a computer screen. Despite my degree from MIT, I am not much of a geek and if this dooms me for a medical career in the future, so be it.

As for P4P, you bet I will cut my more noncompliant patients loose. Below are a couple of examples. I recently diagnosed a 35-year-old male as diabetic and sent him home with a free monitor, logbook, prescriptions, and all kinds of instructions and educational materials (that office visit was a real dog and pony show). A week later, when I asked to review his logbook of home glucose monitor readings, he said he had none. When I asked why not, he admitted he had not purchased the glucometer test strips necessary to perform the home monitoring of his blood sugars. When I again asked why not, he stated that the cost of $85 for a three-month supply was too much (apparently his insurance did not cover this although they pretty much paid for everything else). I asked him if he had cable TV. He looked at me like I was demented and told me, “Of course I have cable TV” I then asked him the cost of one month of his cable TV. As it turned out, it was about $85. I told him that since he did not consider his health to be worth the cost of one month of cable TV he should know that, as an old dude, I can remember when there was no TV at all and that no one died from the lack of TV. I explained that he was definitely at increased risk of dying prematurely if he did not monitor his sugars. His response? He did not return for any further visits. I guess I do not have much of a future as a diabetes educator. Had he returned, I would have tried further education and done my best, with or without his compliance, to treat his diabetes and minimize the complications thereof. However, under P4P, this idiot would have been instantly dismissed from my practice. I’ll give you another example. I was treating a slightly older diabetic lady whose sugars would not come under what the guideline defines as good control. During a long discussion about her diet (which she stated she was following), she revealed that the previous day she had a McDonalds cheeseburger and fries for lunch, and a dinner of stew with lots of potatoes and dumplings on top (carbs, carbs, and more carbs). She then admitted that she had peanut M&Ms for snacks and dessert, as they were her favorite. When I protested that this was a diet that would drive her sugars through the roof and cause her to have preventable diabetic complications (including death), she stated, “I do not want to die, but I am not going to live that way” (meaning without M&Ms, dumplings, potatoes, etc).

Currently, I have agreed to try to work around her non-compliance as best I can, but when P4P becomes a reality I will be placing this lady on a slippery slide out of my practice and blocking the entry into my practice of other non-compliant individuals that my peers have just fired. Luckily, the incentives offered so far for P4P are so puny that I am totally unmotivated to do anything to join this movement. I mean, give me a break, 1.5%? My little solo practice is about a $500,000 a year business. A 1% bonus would amount to $5,000, or less than $500 per month. Big whoop! Even a 5% bonus would amount to only $25,000 per year and for this I would probably have to spend around $50,000 to obtain an EHR and $15,000 a year to maintain it. Excuse me for being underwhelmed, especially when I consider the hassle of changing my whole practice to accommodate the EHR. Thanks, but no thanks. And should this become, as I suspect, an unfunded mandate from the insurers and their lapdog, the government, well, cash only practice is looking better and better.

Everest A. “Tad” Whited, MD, PhD

[tags]Pay for Performance, P4P[/tags]