Health for life

The look of cooperation

Medicare continues to move forward with its PRQS "value-based" fee schedule modifier that will adjust physician payments up or down by 2% and 1%, respectively. 

As the Disease Management Care Blog understands it, 2013 physicians quality and cost data will be compared to peers, and the docs who are above and below the mean will be correspondingly financially rewarded or dinged starting in 2015.  While the American Medical Association continues to quibble over the details, this Affordable Care Act pay-for-performance (P4P) train has left the station.

Unfortunately for CMS, plenty of research suggests that it remains an open question whether PRQS will have much of an impact. For example, findings from this Ontario study indicate that incentives tend to reward physicians who have already achieved the quality thresholds, doing little for the docs who are behind.  Additional research shows physicians may not agree with the underlying methodology and distrust the reliance on insurers data, leading to a willful disregard of the incentives.  And then theres this expert survey that suggests that the effort it takes to achieve low single digit digit changes in income may be viewed as not worth the trouble.

The DMCB also thinks there may be another under-recognized issue at stake. While fee schedule changes in the 1% to 2% range can make a big difference to large hospital-physician organizations, that money, thanks to these organizations byzantine internal accounting and transfer pricing, is unlikely to trickle down in a meaningful way to their employed physicians paychecks. 

Ouch.

Physicians and P4P may turn out to be like cats and going for a walk.



Image from Wikipedia

Joanne Wu, writing in the Annals of Family Medicine, suggests that we dismantle the health insurers "pay for performance" ("P4P") programs in favor of "pay patients for performance" (PP4P).  As blood pressure control, cholesterol treatment, cancer screening rates or fitness rates increase, she proposes that patients receive "health care credits" in the form of lower co-pays, discounts or premium reductions.

Good idea, says the  Disease Management Care Blog, but:

1) Long standing regulations stand in the way. Health insurance regulators generally frown on programs that compromise community-rated risk pooling that gives everyone the same benefit for the same price.  ERISA-protected plans, on the other hand, have greater latitude in flexing their insurance benefits. 

2) Politics stand in the way. Opponents argue that persons less well off will be unfairly disadvantaged by wellness incentives.  You can read more about that here. 

3) Doctors stand in the way. Last but not least, insurers generally fund P4P by diverting the money from the providers inflation-adjusted or market-driven fee schedule increases.  In other words, taking P4P money from the docs and giving P4PP to the patients aint gonna easily happen.

That being said, the DMCB thinks Dr. Wu may be onto something.  She recommends a pilot be tried in a small community.  Given the downstream savings, wed be foolish to not take every advantage we can to achieve patient buy-in, and a pilot sounds like a grand idea.