Thursday, March 8, 2012

Pay For Performance: A Medicare Failure

I'll be honest. When it comes to Medicare rules and regulations, I, like so many Americans, am a little lost. The whole system is incredibly complicated. But I learned something rather disturbing about this complex system this week at the clinic where I volunteer.

I was talking with an attending physician about a patient who had various comorbidities (multiple conditions that interact with each other). This patient was not doing well. The physician told me that under Medicare, the doctor caring for that patient would be in trouble. Why? Because the government has, over the last several years, been instituting what is called P4P - Pay For Performance - measures. These measures reward doctors, hospitals, and other facilities for patients who meet certain "quality metrics" - i.e., do well - and penalize them for patients who do poorly.

On the surface, this might seem like a good idea. Because the goal is indeed a good one: improve quality of care for Medicare patients, while reducing costs and preventing unnecessary expenses. But, it seems, these measures are coming at a cost to some patients who have complicated health issues or a poor prognosis.

In a 2009 opinion piece published in the Wall Street Journal ("Why 'Quality' Care is Dangerous"), the authors referenced a study from California in which "doctors dropped noncompliant patients, or refused to treat people with complicated illnesses involving many organs, since their outcomes would make their statistics look bad." Another study these same authors talked about "indicates that report cards may be pushing Massachusetts cardiologists to deny lifesaving procedures on very sick heart patients out of fear of receiving a low grade if the outcome is poor."

Clearly, this cherry-picking of patients is not what the Medicare rules are intended to encourage, but this is what is happening, in some situations. As I said, these regulations have a good intent. But for complicated cases, they seem to be worsening patient care, not improving it.

Do I have a solution? Unfortunately, no. But I don't think this is the solution, at least in a broad application. One option, perhaps, is to make exceptions for those more complicated cases. But that seems like a logistical nightmare - where would you draw the line?

When I have talked with doctors about my own desire to enter the field of medicine, many have referenced increasing regulations - both from the private and public sectors - as complicating their ability to properly care for patients. Do we need to control costs? Yes. Do we need to improve care? Yes. But not by faulting practitioners for cases in which patients don't adequately improve. And not by encouraging practitioners to drop patients who aren't likely to see that improvement in the near future. While the goal of P4P may be a good one, the outcome seems to be lose-lose, for both patients and doctors. And if both parties are big losers, then a set of regulations that aim to improve care by issuing report cards receives, in my book, a big fat "F" itself.


  1. Great post!! And certainly a good topic for a med school interview!!

  2. BTW, when are you going to change your blog title to include PhD too??

  3. Yes, I definitely want to talk about Medicare in my medical school interviews. There's so much to say about it! Not that I have all the solutions, but at least recognizing the problems is a start.

    And about changing my blog title to include PhD - DONE! Thanks for the reminder! :-)

  4. Much exceptional and educative post certainly.

    Medicare America