Pay for performance (P4P) is touted as the magic bullet du jour for our healthcare cost concerns. In mid-2005, CMS released
its "Quality Roadmap" aimed at delivering "the right care for every person every time." Consistent with this initiative, CMS
has published quality measurements and information directed toward the beneficiary, the provider and, ultimately, the purchaser
audiences.
As purportedly reliable and uniform measures to improve patient care are being tested in the P4P arena, CMS has staked out
a pivotal role. Its payment strategy is to provide incentives to practitioners for doing the right thing—improving quality
and avoiding unnecessary costs—rather than directing more resources to less-effective care.
While measures to ensure quality and safety and enhance patient care are welcomed as laudable improvements, specters of "denial-based"
managed care must be addressed to ensure the success of P4P. Concerns persist that quality and performance efforts may be
covert strategies to cut physician reimbursement and reallocate resources. Some see P4P as a facile excuse for template-driven
cookbook medicine achieved at the diminution of clinical judgment.
These concerns are exacerbated by the variations of evidence for appropriateness of care. Translating varying degrees of evidence
into straightforward guidelines raises significant questions regarding the validity of such evidence, especially when guidelines
for different medical conditions result in conflicting recommendations for patient care. It is imperative to understand why guidelines derived from impeccable evidence are ignored or not routinely followed. The
clinical community is reluctant to adopt guidelines for diverse reasons—the infancy of the new science of evidence, the plasticity
of degrees of evidence and the need to make decisions even when evidence is not strong. It also is easier to implement guidelines
and clinical pathways in facility settings. Until we have electronic health records that include drug samples and lab results,
administrative claims data is a poor substitute for measuring clinical status. These issues pose significant challenges in
progressing with P4P.
WHAT WE NEED TO SUCCEED
The challenges are exacerbated by unsubstantiated claims that when consumer- directed healthcare (CDHC ) is fused with evidence-based
medicine, society can get a handle on the root causes of increasing healthcare costs. These claims must be balanced against
the difficulties the consumer faces processing, understanding and applying pertinent healthcare information. Furthermore,
data is emerging that CDHC may succeed because of cherry-picking healthy people, not because of better care. Despite imposing
a market-driven mentality that consumers can shop based upon price and quality, CDHC will not succeed until the challenges
are understood and addressed.
Few would argue against defined guidelines, developed with high degrees of methodological rigor. Moving from clinical anecdotes
to reliable, verifiable and observable outcomes is something we want to endorse and promote.
When science shapes and enhances the art, and when transparency fuels decision making and determination of priorities, we
have a more dependable foundation on which to build. Building upon such a substrate will add value to performance measures
and thus validate that they positively affect patient care.
Joel V. Brill, MD, is chief medical officer of Predictive Health LLC. Dennis Robbins, PhD, MPH, an MHE editorial advisor, is an industry consultant on ethics and related issues for national organizations.
