The Way I See It: Report cards deserve an F

December 16, 2005

A numbers-only P4P agenda shouldn't reward—or punish.

Like most of you, I received reports cards and grades for 30 or so years of my life. From first grade through medical school, evaluations on rotations as a resident, and in certifying exams, I've been assessed, measured, monitored, and ranked by authorities in every way except jacket size (42 regular) and have always simply accepted it.

But I object to ways in which I'm being scrutinized-and even coerced-today. "Report cards" and "pay for performance" (P4P) are being touted as wonderful tools to correct all the evils in medicine, which some would have us believe are the fault of dastardly, cheating, money-hungry physicians. These instruments need to be understood for what they are, and, perhaps even more importantly, for what they are not. Proponents claim that patients will benefit and deserving physicians will be paid more. While this is theoretically possible, practically speaking, there are inherent flaws.

Using these tools to oversee physician behavior and prescribing patterns doesn't address the primary, fatal defects in the overstrained, fragmented, and anticompetitive national healthcare delivery system. Government programs confound physician compensation from Medicare and have had the unintended consequence of effectively predetermining the price of medical procedures and office visits. Private insurers have little incentive to pay more than government rates and exercise this leverage with impunity. Insurance companies can also intimidate physicians and attempt to influence their decision-making with financial disincentives tied to initiatives like P4P.

I've received a number of reports criticizing me for not having every single one of my diabetic patients on ACE inhibitors. There's no allowance for the number of patients allergic to ACE inhibitors or those also allergic to the related AT2 blockers. Nor do they factor in the extra time I must spend with my patients to uncover this crucial information.

P4P programs that base their financial incentives solely on cost are unethical and unacceptable. These measures should take individual circumstances into account and apply only in areas with a clinically relevant evidence base.

Further, a cold, formulaic calculation doesn't reflect the fact that sometimes patients simply choose to relocate, change employers, or switch doctors. They also decide whether or not to visit the doctor. There's no room on insurance forms for me to point out these facts or explain singular variables. Without such recourse, a report is merely a numerical-and often, grossly inadequate-means of assessment.

Doctors know that investments in preventive health only pay off over the long term, yet report cards are tied to a balance sheet that doesn't tally the time spent in nurturing a patient. The example of Mrs. Priscilla comes to mind. Her diabetic complications and age were already advanced when she first became my patient. Perpetually glucose toxic, she was sedentary and enjoyed a steady diet of Krispy Kreme doughnuts. After years of promoting a course of care, I see her labs now show excellent control of her diabetes. Had I been graded on her progress at any point along the way, however, Medicare would have sent a lynch mob after me. Their report cards don't have a little "shows improvement" box that can be checked. Under P4P, my practice would be better off if I dismissed the next Mrs. Priscilla-but where would she go for care?