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| Archive : Fall
2006 |
FOR A FIVE-STAR RATING AND MAYBE A SMALL BONUS, DOCS MUST:
Track dozens of performance measures // Sift through hundreds of patient records // Swallow thousands of dollars in overhead costs—when all they want is to deliver better care.
The Quest for Quality [page 4]
 By Linda Keslar |
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For physicians in one of the nation’s largest P4P experiments, it appears that fear of notoriety, not money, is the force motivating them to meet the program’s performance goals. Now up and running for five years, the Integrated Healthcare Association (IHA) program brings together six California health plans involving 215 medical groups and 35,000 physicians who, combined, provide care for 8 million enrollees. The $60 million in bonuses the plans have distributed to participating medical groups represents only about 1.5% of total compensation from those health plans. But each medical group also receives a consolidated scorecard, accessible on the Web, that bestows as many as four stars based on performance in three areas: clinical measures, patient satisfaction and use of information technology. “No one wants to see the name of his or her medical group up there with only one star,” says Stephen M. Shortell, dean of the School of Public Health at the University of California at Berkeley, who helped design the project.
Early measurements in the IHA pilot have shown impressive gains in such categories as childhood immunizations, cervical and breast cancer screenings, cholesterol screenings and patient satisfaction. And some IHA health plans have seen reduced hospitalizations, especially in patients with diabetes. Yet James Naughton, an internist in San Francisco’s East Bay with Alliance Medical Group, which has tracked several dozen P4P measures as an IHA participant, worries about hidden costs and data errors that can unfairly stigmatize physicians. He cites the example of a patient who has a family history of diabetes but who doesn’t have that condition himself. “If the tracking system wrongly identifies him as diabetic, it will appear as if he’s missing many required tests,” says Naughton. “You get the code wrong, and you look like a terrible doctor.
“Philosophically, I have no problems with P4P,” he says. “But the cost of participating has been grossly underestimated.” The bonus money the 15 physicians at Alliance have received hardly covers the expense of participation, according to Naughton, despite the group’s sophisticated information technology system. “The time I spend in front of my computer eyeballing numbers, the staff time it takes to make follow-up calls, that’s all pure overhead,” he says.
For physicians to score well on IHA’s performance measures, patients must be up to date on recommended tests and screenings, and making sure that happens is also time-consuming, says Naughton. Moreover, he finds there’s only so much physicians can do to prompt patient compliance. “If patients refuse to follow recommendations, how do you account for that?” he asks. “Our argument is that once we’ve informed them what they need to do, the quality event has occurred, even if they choose not to follow our advice. Either way, a patient’s noncompliance isn’t counted against us.”
Working out P4P issues has taken on new urgency since the AMA struck a deal last December with key congressional leaders. In the agreement, the AMA promised to develop approximately 140 physician performance measures covering 34 clinical areas by the end of 2006, and to ask physicians who agree to participate to begin tracking performance as early as 2007.
The deal, which the AMA negotiated on its own, didn’t sit well with many physicians. Medical specialty groups, many of which are gaining members at the AMA’s expense, worried that the broad measures the AMA agreed to create would not reflect the realities of specialty practices. What’s more, officials representing 10 national medical societies and 200,000 physicians complained in a letter to congressional leaders that the AMA hadn’t consulted with them before signing the agreement. |
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Photo by Sarah A. Friedman |
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