Pay for performance likely to become physicians' reality

"P4P seems to be a number of things: a marketing slogan from Congress; a revenue shift to primary care; a quality initiative; a means of looking at new technology and an initial foray into evidence-based medicine; and a means of cost control. Why are we in society talking about P4P and quality?" Dr. Rich asked.

In answer to that question, Dr. Rich explained a number of problems in medicine. He is clinical instructor in ophthalmology, Georgetown University Hospital, Washington, DC, and medical director of health policy for the American Academy of Ophthalmology.

Some other factors that are forcing P4P to the forefront are the beliefs that improved quality and efficiency will lower costs, that information technology will lower medical errors, that performance measures will enable patients and purchasers to differentiate among providers of care and enhance patient choices, and that pay should reflect that quality and efficacy of the care delivered, Dr. Rich explained.

In addition to those, there is an idea that too much of what physicians do is based on anecdotal evidence, and that the necessity for these practices is uncertain. Finally, new technology is recognized as not being evidence-based but manipulated by industry through the political process, Dr. Rich said.

"Medicare pays for positron emission tomography (PET) to detect early Alzheimer's disease. First, PET imaging does not pick up early Alzheimer's disease. Second, if it is detected, what do we do with it?" he pointed out as an example of political manipulation of industry.

The ophthalmology response

Another question Dr. Rich posed is: Why are physicians listening to society's demands to begin meaningful quality measures? The bottom line is basically money, he said.

"With the rapid growth in spending on drugs, imaging, and office-based diagnostic testing, ophthalmologists can expect huge cuts in physician reimbursements over the next several years-24% by 2012," Dr. Rich explained.

"Congress, MedPac, the advisory body to Congress, and the Centers for Medicare and Medicaid Services (CMS), have said that P4P should be an integral part of physician payments and Congress will not address the cuts in physician reimbursements without a commitment of medicine tied to the national Medicare Pay for Performance program," he said.

Dr. Rich said he believes medicine has failed in implementing quality-control measures.

"Medicine has failed with preferred practice patterns and with continuing medical education activities," he said. "However, monetary stimuli do seem to work."

Assessment of performance

The definition of performance assessment is as follows: physician clinical performance assessment evaluates individual doctor's clinical practice behavior and adherence to objective standards of clinical processes of care, thereby holding the physician accountable for practicing according to those standards.

The practices, according to Dr. Rich, must:

The measures include information technology, processes of care performed daily by physicians, outcomes measures, and efficiency measures.