hether we like it or not, pay for performance (herein “P4P,” encompassing the broad umbrella of these initiatives) has arrived. Make no mistake: Change in how health care is paid for in our country is coming with the force of a hurricane; a hurricane with more potential to alter our approach to the practice of medicine than any other event before. The only question for us is: What is the best course of action for the anesthesiology community?

The current lack of “evidence” demonstrating that P4P arrangements improve quality of specialty care has become a rallying cry for the opposition to this initiative.^1,2 It is important to remember, however, that we have modified our practice before in the absence of compelling data (see, for example, pulse oximetry and capnography). It would be difficult to argue, despite lack of evidence and the cost involved in making these monitoring techniques “standard of care,” that use of pulse oximetry and capnography have not improved patient care and helped to establish anesthesiology as the safety-conscious medical specialty. The questions that are most germane are whether or not the proposed changes are reasonable, if it is possible that such changes will improve outcomes and if the process will constitute an unacceptable burden on our practice.

It is difficult to contend that the U.S. health care system does not need major reform. Today we are faced with a choice — either embrace the opportunity to play a defining role in the makeup of P4P for our specialty or sit on the sidelines and let others shape the change. P4P programs are a first step in the realignment of health care from a volume-driven to a value-based system. It will take time for the fine granular data of this change to be available for analysis, but change will start somewhere. Why are physicians a good place to start? Physicians generally intend to provide compassionate, high-quality, cost-effective care, but it is increasingly obvious that payment systems inhibit and frustrate those efforts. As anesthesiologists we are the clinical managers of one of the most important and costly components of America’s health care system — the perioperative process. We must take the lead to create payment systems that encourage redesign of processes of care to promote higher value. Studies have documented that nearly one-half of physician care in the U.S. is not based on “best practices”³ and that at least 98,000 Americans die annually from medical errors.⁴ These same studies correctly acknowledge our specialty as a model of patient safety. As a model specialty, we know that there is always room for continued improvement. This imposes on us a special responsibility to continue moving the process of safety-based, patient-centered care forward.

Physicians rightfully complain about the lack of a true market-based health care system whereby “consumers” (sic “patients”) buy services from “suppliers” (sic “physicians”) who set their own prices and design their own services. Movement from a volume-driven to a value-based system is a small but positive first step in that direction! In this regard, our goals as physicians are aligned with those of our patients. Patients want health care that is a good value, defined as high-quality (safety, expected outcomes and first-rate service) at a reasonable price, and physicians want a fair market payment for their services. Rather than try to derail P4P, we as physicians need to channel the broad pressure for change into the value-based system WE WANT!

Value = Quality (Safety, Outcome, Service) + Access
Cost

In this regard, P4P should be viewed as an opportunity rather than an adversary. The key is for us to define what constitutes quality and play a significant role in defining access and measuring cost. The opposing point of view sees payers “influencing” each of the components of this equation. Yet this view ignores the overall imperative for change. In the absence of physician involvement, this is exactly what will happen if we fail to participate in the evolution of P4P. For example payers could attempt to define quality and therefore determine the outcome of key medical decisions. One could argue that if that “influence” is an encouragement to pursue “best practices,” it is no bad thing. Our involvement in the process will allow us, and not payers, to define what performance measures constitute best practice and, more importantly, ensure that the definitions are continuously refined as ongoing research identifies “better” practice. If we are involved, P4P has the potential to induce positive change in practice and provide the impetus to evolve our specialty in ways that are crucial for our survival. Another argument is that payers will demand excessive record-keeping. This can be an issue, and all P4P programs need to have an acceptable participation burden — this is another key reason why we must be part of the system’s redesign. Our involvement will allow us to influence how the chosen performance metrics should be measured. Nonparticipation will lead to “imposition” rather than collaboration.

A final concern involves cutting costs below that which is economically viable. A cynic will look at the equation on this page and argue that by lowering the denominator, i.e., cost, “payers” can raise the value by sleight of hand. This approach, however, would be self-defeating (see every capitation failure of the 1980s and 1990s). There are at least two unintended consequences of reduced capital inflow into the system that would be catastrophic. First, decreased revenue will force physicians to deny care with a resultant decrease in access. Second, that decrease in access will produce a lower value in the form of reduced safety and poorer outcomes along with further dissatisfaction among patients and physicians. In the end, this will cost the payers more!

The ethicist and neonatologist Richard E. Thompson, M.D., has posed the query, “Is pay for performance ethical?”⁵ He contends that a payment scheme that intends to establish inequality in pay between individuals or groups working in the same area of an organization is unethical! This argument is illogical. Rather P4P may be the basis for delivery of health care via a quality-resolute, free-market-centered economy. It is far more reasonable to state that our current system, whereby high-value and low-value physicians receive the same compensation despite differential quality, is unethical!

We, as physicians, are ethically bound by the oath Primum Non Nocere and the duty to best serve the interests of our patients. When seen in this context, we have a clear mandate to participate in the realignment and redesign of a system that has large gaps in quality and safety, spiraling costs and a perverse payment scheme that inhibits access to care.

Why should we participate? Because no one, absolutely no one outside of anesthesiology understands what we do and the true value we bring. The bizarre and ridiculously low valuation of anesthesia services by the Centers for Medicare & Medicaid Services is a direct reflection of this fact. Can you imagine what a committee composed of cardiac surgeons, obstetricians, family practitioners and dermatologists might decide constitutes the “best practice” of anesthesiology? The thought alone is horrifying!

We simply must participate — there is but one choice.


References:
1. Rosenthal MB, Frank RG. What is the empirical basis for paying for quality in health care? Med Care Res Rev. 2006; 63:135-157.
2. Petersen LA, Woodard LD, Urech T, Daw C, Sookanan S. Does pay-for-performance improve the quality of health care? Ann Intern Med. 2006; 145:265-272.
3. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003; 348:2635-2645.
4. Kohn LT, Corrigan JM, Donaldson MS. To Err is Human: Building a Safer Health System. Washington, DC: National Academies Press; 1999.
5. Thompson RE. Is pay for performance ethical? Physician Executive Nov-Dec 2005.

Gerald A. Maccioli, M.D., F.C.C.M., is Director of Critical Care Medicine, Critical Health Systems of North Carolina, Raleigh Practice Center, Raleigh, North Carolina. He is ASA Director for North Carolina and President of the American Society of Critical Care Anesthesiologists.

Pay for Performance — CON

Kenneth Y. Pauker, M.D.
Committee on Governmental Affairs
Committee on Performance Outcomes Measurement

What gets us into trouble is not what we don’t know; it’s what we know for sure that just ain’t so.

— Mark Twain

ay for performance is a notion that alleges to affect positive change in America’s dysfunctional health care sector. Concomitantly touted and decried, P4P in the abstract and in our vernacular encompasses so many iterations that one must articulate precisely just what one means to discuss. What P4P portends for you or me as potential “recipients” is different from what it represents to “them” as “purveyors” of P4P. Just “follow the money.”

Vice-President for Professional Affairs Alexander A. Hannenberg, M.D., asserts that the question of whether “physician performance [should] be linked to performance” is answered, and by implication, settled. Bill Plested, M.D., President of the American Medical Association, describes P4P as “totally unproven,” “unethical” and “patently absurd.” Some fear being left behind. Others remain skeptical about the entire notion. Some ASA leaders see the potential to create an alternative payment gambit that might redress our longstanding undervaluation by the Centers for Medicare & Medicaid Services’ flawed Resource-Based Relative Value Scale. The party line at ASA: “P4P is more of an opportunity than a threat.”

P4P is about linking payment to desirable outcomes, not paying for “mistakes,” purchasing services of higher “value.” It’s like “motherhood and apple pie,” so how can anyone be opposed? Here’s how. P4P has become a sound bite, a mantra, a raison d’etre for a whole new posse of tinkerers. Some planners promote it as a paradigm shift in payment for services, but there is no data to show that it will help and not hurt anesthetized patients. How P4P is rolled out defines what it is.

Despite examples of P4P improving adherence to certain quality measures, its dark underbelly is awash in well-documented perturbations of established medical practice, unintended consequences that can degrade care. Published studies demonstrate that: P4P redirects payments to groups already in compliance; compliance shows only marginal or no improvement in patient outcomes; physicians “game” the system; physicians avoid high-risk patients; there are no valid risk-adjustment methods; and minority populations are at risk for losing access to care. An artifice to pay less under the guise of seeking value, P4P intends to drive resources from specialists to primary care but ultimately will pay both less for more effort and hassle.

P4P evils include nonphysicians influencing and making medical decisions, faulty performance measures, additional record keeping and uncompensated overhead, over-emphasis on cost cutting, unfair and inequitable program incentives and risk of corporate compliance issues. There are unethical ploys: using P4P to serve public relations or political purposes, rewarding individuals or entities for results they themselves did not cause, reducing care via P4P criteria and payers using P4P to micromanage patients’ care.

Moreover, P4P incentives interfere with a physician’s fundamental ethical duties to the individual patient. Medicine is a moral enterprise and a moral community. According to ASA’s ethical guidelines, we are obliged to behave altruistically, setting the interests of the patient above our own self interests. P4P obliterates the distinction between whose interests are paramount.

How does P4P appear to be developing in our own specialty? The ASA Committee on Performance and Outcomes Measurement (CPOM) insists on vetting each measure according to carefully constructed rules because performance measures will become standards of care. Palpable tension exists between those ASA leaders who insist that P4P measures must be advanced rapidly and those trying to restrain the process. The normothermia measure — still under development and debate — was “extended” to capture more potential economic return for ASA members, and in so doing crossed a chasm from science to business. Follow the money. The antibiotic timing measure may potentially capture P4P dollars, but it has little to do with the skills we bring to our patients as physicians. Moreover, while hospitals may be paid for this P4P measure, anesthesiologists likely will not.

Nonetheless P4P appears to have gained sufficient traction that we are told that it is impossible to “force the genie back into the bottle.” Beyond merely payers, hospitals with contracted anesthesiologists who are paid stipends for anesthesia services are starting to make additional demands under the rubric of P4P. The refrain has become: better and cheaper care, or at least increased value for payment rendered. Unfortunately, because value is defined as access plus quality divided by cost, one can more easily “create” value by reducing cost than by enhancing quality.

Value = Access + Quality/Cost

There are alternatives to P4P. Payers (including the government) must invest in health information technology. Specialty societies should mine the data (as with the ASA Closed Claims Project) and then set evidence-based standards and performance measures that enhance quality. Specialties could then construct benchmarks and provide detailed individual data to change individual behavior nonpunitively. Each specialty should demonstrate quality improvement, and there should be collaboration between specialties in areas of common interest and expertise. Setting up a system of cutthroat competition between individual physicians within or across specialties will only exacerbate divisions within the House of Medicine and hasten the demise of our profession. Physicians and patients must be aligned and drawn together; intermediaries that pervert that relationship should be minimized and marginalized. Each specialty must address its unique inefficiencies and instances of profiteering and demonstrate this effort to payers. Further manipulations to squeeze additional “profits” and/or savings from already “pruned out” physicians must cease; instead, cost savings should be sought from “big ticket” items. The “big gorilla” items of waste and cost, such as outlandish health insurance industry profits and nonbeneficial care at the end of life, must be debated and addressed by Medicine, society and government. We must tackle the thorny issue of what level of medical care our society can afford for all.

Regarding tactics, what would happen if someone gave a P4P party and no one showed up? A few might be there to collect some payments, and perhaps some few would profit economically, but if an insufficient number of physicians participated because of practical or philosophic reasons (perhaps a professional society might declare participation in certain P4P schemes to be unethical and therefore unprofessional conduct), then the P4P train might slow or even stop. I submit that if we do not change how we conduct business compared to our history, we will over a relatively short time see our specialty become irrelevant.

Kenneth Y. Pauker, M.D., is an anesthesiologist in private practice, Saddleback Memorial Medical Center, Laguna Hills, California. He is Chair, Division of Legislative and Practice Affairs, California Society of Anesthesiologists.