Pay for performance
Your recent article on the problems involved in monitoring quality indicators for patients with multiple conditions showed an appreciation for the complexity of pay for performance. ("Study finds generation gap in guidelines," December 2005 ACP Observer.) However, I am concerned that ACP has a position on pay for performance that is not in agreement with its members.
I have been told that the College is involved in national pay-for-performance initiatives because the implementation of such programs is inevitable. But the rhetoric coming from College leadership—and the lack of Congressional support for such initiatives that I have found during my Leadership Day visits—indicate to me that ACP is pushing for these programs.
In the June 3, 2005, issue of Medical Economics, Robert B. Doherty, ACP's Senior Vice President for Governmental Affairs and Public Policy, criticized the present system for "reimbursing doctors based on service rendered, not results." In a better system, he said, doctors "would be rewarded for delivering constant care consistent with evidence-based guidelines and measures." It is as though this unproved system is the ideal when, in fact, early experience with pay for performance—including results published in the Oct. 12, 2005, issue of Journal of the American Medical Association (JAMA)—showed little gain in quality for the money spent.
I realize ACP is trying to justify increased reimbursement by promising better quality. But the federal government is not going to find more money and has already proposed reducing physician payments by 2%, then giving that amount back as pay-for-performance incentives. By advocating for pay for performance, ACP is emboldening Congress through the Centers for Medicare and Medicaid Services to take that step.
It has also been proposed that the use of information technology will reduce errors and make practice more efficient. A study published in the March 9, 2005, issue of JAMA, however, indicated that a computer system contributed to prescription errors, rather than reducing them. It is too soon to make sweeping judgments about the utility of information technology—or such major investments of time and money.
I know the College is highly committed to both pay for performance and information technology. But it is not too late to have second thoughts. Pay for performance will be expensive and will interfere with the physician-patient relationship.
It will also eliminate the last vestige of physician autonomy, aggravating the present tide of general internists being driven away from accepting third-party payment or out of practice altogether. Physicians should not be apologists, promising to practice more efficiently. Instead, we should demand better remuneration to keep our standards high.
Jerry F. Meyer, FACP
Mr. Doherty replies: ACP shares many of Dr. Meyer's concerns. Instead of acquiescing to poorly designed pay-for-performance programs, the College has decided to be at the table to make sure such programs are based on the best medical evidence; minimize the burden of collecting and reporting data; and provide adequate, sustained reimbursement for quality improvements.
We also believe that the effectiveness of pay-for-performance programs to improve quality will be limited as long as Medicare and other payers continue to pay physicians based on their volume of services, rather than recognizing the value of managed and coordinated care.
The College believes that a well-trained internist, using systems of care based on patients' needs, will be shown to provide the best value in the health care system. We are committed to developing and advocating for new models of care delivery and financing—such as the recently proposed advanced medical home model—that would support the value of care managed by a personal internist. (See the policy monograph online.)
However, we cannot persuade payers that internists deserve better remuneration based on our word alone. If designed correctly and with the College's involvement, performance measurement and reporting—combined with fundamental changes in physician reimbursement—will enable us to demonstrate the value of internists' services. By doing so, we hope to achieve the higher reimbursement that Dr. Meyer and other College members so rightly deserve.
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