May 7, 2007
Student Scene
Pay for Performance: Rebuilding Care Delivery from the Ground Up
Rachel Eastwood
Jason Sanders |
Pay for Performance (P4P) makes the top 10 buzzword list across most academic medical centers. Policy buffs are keen to roll it out in Medicare. Nearly every bulletin of the Massachusetts Medical Society provides an update on its glacial implementation, often citing legitimate concerns about risk-adjusted metrics. It’s an easy sound bite for politicians, something sensible, downright self-evident. Who wouldn’t pay for performance in a professional field?
The frustrating question is what do patients (and society more broadly) get for every health care dollar expended? Outlays that should be partially an investment in future health (for example, better perinatal outcomes or longer life expectancy) have yet to rise above cost status in many payor budgets, including the federal government’s. It’s hard to find fault with the argument that scarce resources demand allocation based on social returns, but the dearth of performance metrics makes quantifying such future value extremely difficult. We are left only with costs and the offsetting yet vague sense that surely things must be skipping along just fine; but are they really?
Many levels of complexity cloud a clear view of how well providers are doing, but I would offer two key challenges to the P4P movement: assigning accountability to practitioners within the care pathway and charting process versus outcome metrics.
Who Cares for Whom?
A recent study by Pham et al., titled “Care Patterns in Medicare and Their Implications for Pay for Performance” (New England Journal of Medicine, March 15, 2007), analyzed Medicare claims data from 2000–2002 for 1.79 million fee-for-service beneficiaries who were treated by 8,604 clinicians. Over this period, patients “saw a median of two primary-care physicians and five specialists working in four different practices ”; the number of providers was even higher for patients with chronic conditions such as diabetes or coronary artery disease. Only 35 percent of patient visits each year were with assigned physicians, and on the flip side, a primary-care doctor’s assigned patients represented 39 percent of the total panel and 62 percent of visits. In addition, 33 percent of patients annually had a change in their assigned physician, and primary-care doctors witnessed a median of 29 percent of their patients changing annually. As much as 11 percent of the patient pool had three assigned physicians over a two-year period.
Karen Davis, president of the Commonwealth Fund, cautioned in an accompanying editorial that the “dispersion of care across physicians and practices” as well as the disruption of longitudinal patient–doctor relationships raises concerns about P4P’s blind spots. Some of the dispersion is driven by patients (who do value autonomy and mobility), but much culpability remains in the hands of providers.
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We need performance measures to reform health care delivery, but the fragmentation of the current system thwarts the usefulness of P4P metrics. |
The American Academy of Pediatrics and the American College of Physicians issued a white paper in March 2007 advocating the “patient-centered medical home,” which highlights coordination between the primary provider and specialists as well as health information exchange. Though not a panacea, IT does offer an obvious vehicle for coordination; how many medical students have looked at a chart or even electronic record that is missing important notes from specialist visits? An example of the inordinate difficulty of pinning down responsibility is the treatment of diabetes: a cardiologist might manage hypertension; a nephrologist might manage renal insufficiency; an ophthalmologist does annual eye screening; a podiatrist tends to ulcers; and so forth. The only way to assign accountability is across the whole team, but the current delivery infrastructure is inadequate for a coach reasonably to manage all these players.
A New Foundation
Another challenge for P4P is the assessment of process metrics in lieu of true outcome metrics. Specifically, consensus guidelines have been used as a process checklist. These interventions can be easier to track, but the critical assumption is that their completion leads to better outcomes.
Recent studies like the one by Landon et al. (New England Journal of Medicine, March 1, 2007) question the reliability of this approach. The group looked at pre- and post-intervention data for the treatment of diabetes, asthma, or hypertension over 4.5 years at community health centers participating in quality improvement initiatives; 9,658 patients were enrolled at 44 experimental centers and 20 control centers. While processes of care showed marked improvement, there were no gains in clinical outcomes; for example, urgent care for asthma, HgbA1c for diabetes, or blood pressure control for hypertension.
But it is real outcomes that will be the linchpin of P4P, and more broadly, it is the accurate and timely publication of clinically significant outcomes that will be the cornerstone of value-based competition in health care, as Michael Porter of Harvard Business School has argued in Redefining Health Care. The disconnect between well-intentioned process improvements and actual end results is highly troubling.
A closer look at P4P shows a chicken-and-egg problem. We need performance measures to reform health care delivery, but the fragmentation of the current system thwarts the usefulness of P4P metrics. How can we track a primary provider’s performance when his patients are seeing five specialists on average each year, and 30 percent don’t even return the following year? How can we track a provider’s performance when adherence to diabetes treatment guidelines don’t lead to HgbA1c reductions? Health care systems—whether community hospitals or major academic medical centers—must be willing to experiment with delivery change and to use performance measures to guide that change. It’s an iterative process, because P4P cannot simply be overlaid on the status quo.
The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.
Research Reigns at Soma Weiss Day
Liza Green, HMS Media Services
People born with paralysis of a nerve on one side of their face need not resign themselves to a lifetime of lopsided smiles. Muscle grafts routinely restore movement to patients with congenital unilateral palsy of the facial nerve. Still, it is not clear where in the brain such movement is initiated. Sharon Fox (top left) observed the brains of patients before and after surgery and found new areas of the motor cortex take over responsibility for the restored movements. A third-year student and one of four student speakers, Fox described her findings at the 67th annual Soma Weiss Student Research Day on April 19. Other student speakers were (clockwise from top right) Ilka Netravali, Michael Lu, and Jeffrey Shackelton. Patricia Donahoe, the Marshall K. Bartlett professor of surgery at Massachusetts General Hospital, gave the keynote on the future of basic and translational research, and more than a hundred students displayed posters.
Copyright 2007 by the President and Fellows of Harvard College