Monday, September 25, 2006

The P4P Band-Wagon Rolls, But in Whose Interests?

We have posted skeptically here and here about pay for performance (for physicians) (P4P), one of the most fashionable notions in health care management circles. Briefly, our concerns were that P4P could lead to perverse incentives (by rewarding apparently better rates of good outcomes which could be created by avoiding the sickest patients, or emphasizing a few measured processes and thus distracting physicians from doing anything else, or being based on inaccurate or irrelevant data), could emphasize cost cutting over quality, and could emphasize processes which have been better studied, potentially penalizing the specialties that did the most research about quality.

Nonetheless, the august US Institute of Medicine (IOM), part of the National Academies of Science (NAS), has recently given P4P another push. According to the Hartford Courant,

In a report to Congress released Thursday, the respected Institute of Medicine endorsed the system called "pay for performance," under which doctors who treat Medicare patients would get paid more for doing a better job.

Since it was enacted in 1965, Medicare has paid doctors for how much they do, said Robert Galvin, director of global health care for General Electric in Fairfield and a member of the Institute of Medicine Committee.

"This is based on how well they do," he said. "That's a big conceptual change."

The system for measuring quality of care is still evolving, but essentially would work this way:

Treatment prescribed by a doctor - including tests, drugs and other procedures - would be measured against a list of scientifically proven standards for treating a given condition. A doctor would gain points toward bonus pay for each standard met.

The new system, which could take years to implement, is designed to save federal money by providing better care that prevents expensive complications and hospitalizations.
Thus the authors of the report did not seem overly worried about the concerns we raised above. The report may also have been written before the publication of a systematic review of pay-for-performance (Petersen LA, Woodard LD, Urech T et al. Does pay-for-performance improve the quality of health care? Ann Intern Med 2006; 145: 265-272.) That review concluded that although there was some evidence of improvements in quality, "in all, 4 studies suggested unintended effects of incentives."

Another question is whose interests the IOM report really represents. The Center for Science in the Public Interest (CSPI) recently released a report about conflicts of interest at the NAS, including the IOM, "Ensuring Independence and Objectivity and the National Academies." To quote its executive summary,

This report focuses only on the selection process for and composition of NAS panels.
In 1997, NAS committees funded by the federal government came under the jurisdiction
of the Federal Advisory Committee Act (FACA). Congress required the agency to avoid using scientists with direct conflicts of interest on study panels (unless their expertise is deemed essential and not available elsewhere) and to seek balance on points of view. This report found serious breaches of both of those rules.
Finding: Nearly one out of every five scientists appointed to an NAS panel has
direct financial ties to companies or industry groups with a direct stake in the outcome of that study
. This consistent pattern of appointing scientists with conflicts of interest clearly violates the spirit of the Federal Advisory Committee Act amendments that apply to NAS.

Finding: NAS did a poor job of balancing points of view on a majority of the study panels examined. The NAS does not appear to consider information about potential bias or conflicts of interest prior to nominating individuals to a committee. As a result, about half the panels examined had scientists with identifiable biases who were not offset by scientists with alternative points of view.

Finding: The NAS provides brief biographies of nominees to its committees on the agency’s website. Such biographies could assist people who were considering commenting on a committee’s composition. However, those biographies are woefully
inadequate because, in a majority of cases, they fail to provide crucial data
regarding conflicts of interest and points of view

The 23 authors of the IOM report on P4P, "Rewarding Provider Performance: Aligning Incentives in Medicare," include several from large corporations presumably in their role as employers (e.g., General Motors, General Electric, and JP Morgan Partners.) Based on CSPI's findings, it should come as no surprise that a there were several others with apparent conflicts of interest which were not revealed in the listing of the committee responsible for the IOM report, that on Redesigning Health Insurance Performance Measures, Payment, and Performance Improvemnt Programs.

Most strikingly, the committee included four people who were members of the boards of directors of 13 various health care corporations. Three of these individuals were identified only as academics, and one only as an employee of a corporation not obviously involved in health care:
Thus the band-wagon for P4P rolls on, but whose interests it represents remains unclear. Clearly industry may see it as a way to cut costs and make more money. Whether it will be good or bad for patients remains unclear.


james gaulte said...

IOM's pronouncements for too long have been treated with blind reverence by the medical community.Their determinations have seemingly been assumed to be free of bias or and immune to conflicts of interests.Transparency seems to not be required for the members on the P4P committee.The various roles played by some of the committee members obviously raises the important question of whose interests are served by their conclusions.

CL Psych said...

Excellent story, as is the norm on this blog. In academics, I have seen various P4P schemes. They generally seem to focus on the latest buzzwords, from "academic excellence", to "advancing the science of the field," to "enhancing student learning," but it seems they are often just a way for administrators to reward the people who are most conversant in the latest set of consultant-derived catchphrases. It is quite clear that if the outcome measures are not legit and there is no control for confounding factors (i.e., I don't take difficult patients OR I don't teach difficult classes), then "accountability" becomes just another buzzword at best. Don't get me wrong, accountability, when measured appropriately is a big deal. In my area of clinical psychology, I am amazed by how few clinicians bother to track their outcomes, but who insist that their clients are generally successful. Um, prove it! Tracking outcomes can lead to accountability, which is good, but only when done so thoughtfully.

Richard A Schoor MD FACS said...

P4P scares me too, and I can certainly see the "perverse" incentives that you mentioned. I just recieved a newsletter in the mail from CIGNA that had an article happily touting their brand of P4P. In essence, physicians who cost CIGNA less will get a [gold] star next 2 their names in the directory. How can I get that gold star?

Richard A Schoor MD FACS said...

P4P scares me too and I can certainly see the "perverse" incentives that you mentioned. I just received the quarterly CIGNA newsletter, in which CIGNA's version of P4P was touted. In essense, physicians that cost CIGNA less will get a [gold] star in the physician directory, the one that patients go to to find a participating providor. How can I get a gold star?