P4P: Between the devil and the deep blue sea?

Key Points

Baltimore-On one hand, the controversial thorn-in-the-side issue of pay for performance (P4P) has large employers, insurers, and Congress contending that the delivery of substandard medical care by physicians is hurting patient care and costing the health-care system huge sums of money. On the other hand, Congress and insurers are determined to reward physicians for providing high-quality health care and at the same time penalize them for delivering lower-quality health care.

"This is the essence of P4P. The concept certainly is worthwhile, but the results may be good or bad for physicians depending on how they are implemented," said John T. Thompson, MD, who discussed how physicians can participate in the process of defining quality care at the Current Concepts in Ophthalmology meeting, Baltimore. He is past president of the Maryland Society of Eye Physicians and Surgeons.

"So just how is quality health care measured?" Dr. Thompson asked. Are some of the parameters patient satisfaction, physician scores on recertification examinations, patient outcomes, and the amount of time spent with patients?

In one such study, the Institute of Medicine estimated that at least 1.5 million preventable adverse drug events occur as the result of incorrect medications, incorrect transcription of illegible orders, and incorrect administration of medications. These adverse events add large costs to hospitalization-specifically, $3.5 billion as the result of 400,000 adverse drug events in hospitals alone.

A study of glaucoma care by community ophthalmologists found that only 44% of patients with the disease commented about the status of glaucoma after their first examination, in keeping with preferred practice patterns for glaucoma that recommend a comment from the patient about glaucoma.

A study conducted at 10 academic medical centers found that 26% of charts of patients undergoing cataract extraction were missing at least one of the following essential pieces of information: the visual acuity in the eye undergoing surgery, the visual acuity in the fellow eye, a fundus examination, and documentation of functional visual impairment.

Developing measures of quality

The problem with the current health-care system is that it encourages a high volume of service and overutilization of testing, Dr. Thompson said. Physicians with poorer patient outcomes and higher complications benefit by receiving more payments to treat those patients, he said, and the system rewards physicians for spending as little time as possible delivering a particular service.

But what is the best way to surmount these obstacles?

The key to developing quality care is physician participation in the process of developing standards, Dr. Thompson said. Physicians are best able to define what measures are the most important indicators of quality. In addition, physicians are in the best position to protect patient interests.

The American Medical Association (AMA) and the American Academy of Ophthalmology (AAO) have formed committees that will define measures of quality that can be used in a pilot P4P system.

The AMA Physician Consortium for Performance Improvement includes health insurance representatives, AMA staff, and 13 ophthalmologists-both general ophthalmologists and subspecialists-charged with the task of developing measurements of quality. In addition to Dr. Thompson, the ophthalmologists include Paul Lee, MD, chairman; Richard Abbott, MD; Lloyd P. Aiello, MD, PhD; Priscilla Arnold, MD; Richard Mellman, MD; Leon Herndon, MD; Kenneth Hoffer, MD; Jeffrey Karlik, MD; Mathew MacCumber, MD; Mildred Olivier, MD; James Rosenzweig, MD; and Sam Romeo, MD.

Ophthalmology measures

"The consortium," Dr. Thompson reported, "has formulated the first set of eight ophthalmology measures for quality health care. These are relatively simple guidelines to field test the concept in ophthalmology."