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  • Pay-for-Performance in Medicare Could Do More Harm Than Good

    Liberals’ solution to rising health care costs has consistently been to take control of health care decisions away from patients and their doctors and to place it in the hands of government. Obamacare does this by allowing unelected bureaucrats to define and reward value in the Medicare program, and the President’s proposal for deficit reduction would further empower government to interfere in the practice of medicine. This is the wrong way to reduce costs, and will have severe consequences for patients, physicians, and the quality of health care in the United States.

    In 2012, Obamacare will create the “Value-Based Purchasing Program” in Medicare. Using a pay-for-performance scheme, the program will reimburse hospitals and other health care providers at different rates based on how they score on performance measures chosen by the Secretary of Health and Human Services. Proponents of pay-for-performance see it as a way to use financial incentives to streamline and improve the quality of health care while attempting to reduce costs. But the fact is that standardization of the practice of medicine costs patients and physicians tremendously, and evidence shows it does very little to improve health outcomes.

    Years of research, including early warnings from The Heritage Foundation, indicate that Obamacare’s Value-Based Purchasing Program and schemes like it will be unsuccessful and result in more harm than good. Studies have since provided evidence to support expectations that pay-for-performance would hurt the doctor-patient relationship, threaten physician autonomy, and deteriorate the quality of patient care in several other ways.

    In 2005, Richard Dolinar, M.D., and S. Luke Leininger wrote for Heritage that pay-for-performance would:

    • Dump patients into a system of top-down, “cookbook” medicine that is incompatible with high professional standards of patient care;
    • Spawn an increasing number of Medicare rules, regulations, and guidelines, further undercut­ting the physician’s professional autonomy and integrity, as well as patient choice and access to care;
    • Undermine the more desirable goal of high quality, which requires personalized care;
    • Retard medical innovation and introduce unproductive gaming by doctors to secure higher Medicare reimbursement; and
    • Further weaken the traditional doctor-patient relationship.

    Researchers for the University of Manchester’s National Primary Care Research and Development Centre in the United Kingdom examined the effects of pay-for-performance programs in the United Kingdom and California for primary care physicians. They concluded that the programs had unintended effects on care and physician motivation, including “encouraging physicians to avoid sicker patients, exacerbating disparities, and neglecting types of care for which quality is not measured.”

    Financial incentives to meet certain performance targets led to the deterioration of the doctor-patient relationship, as physicians “expressed resentment about patients who refused to comply with their advice.” According to the authors, “interviews contained reports of seriously dysfunctional or coercive behavior” by doctors in cases where patients were noncompliant. In extreme cases, doctors threatened to disenroll their patients, accused patients of hurting their rating, or lied about the consequences for failure to comply. Physicians even reported disregarding informed consent procedures to meet screening targets for certain diseases.

    Finally, the study found that pay-for-performance was perceived by physicians as a challenge to their professional autonomy, and that the care they provided was imposed upon and managed externally. The authors write, “The system was viewed by many as unfair and opaque because it failed to take account of variations in practice populations, comprised indicators that were not amenable to control by physicians, withheld money that was due to physicians, and added to workload.”

    Rising health care costs are a serious concern that must be addressed, and lawmakers are correct to look for solutions that solve the problem without damaging the quality of health care in the United States. However, creating a pay-for-performance program within Medicare will do the opposite, as will any other changes to the program that give bureaucrats—not patients and doctors—more control.

    Posted in Obamacare [slideshow_deploy]

    8 Responses to Pay-for-Performance in Medicare Could Do More Harm Than Good

    1. Ted Bakowsky, San Le says:

      I think that pay-for-performance will likely cause many people to distrust their doctors because they will perceive that their doctor has, in effect, become an agent of the Government and must do whatever the Government dictates. This will severely damage the doctor-patient relationship and can cause many people to avoid seeing their doctors.

    2. West Texan says:

      Well said. Far left regressives neither grasp the meaning of American federalism nor elementary economics. Who elected all these clowns?

    3. Sal Alomia, Savannah says:

      While I certainly do not disagree with the entirety of this article's content, I think the author is misguided in attributing Value-Based Purchasing to Obama. The fact that CMS finally got around to issuing the VBP Proposed Rule during his administration doesn't mean that it's Obama's. In fact, VBP's foundation lies in Bush's Value-Driven Health Care Initiative. I'd encourage the author to be fair in her attribution of the program.

      I agree with the author that measures need to be taken to prevent access limitations and degradation of the patient-physician relationship – however, I think we can all agree that putting modest financial incentives in place that encourage better care quality, outcomes and patient satisfaction is a step in the right direction. The current laissez faire healthcare system we have here is rampant with excessive avoidable admissions, unnecessary readmissions, and preventable adverse events.

    4. George Colgrove VA says:

      Agreed, the best plan is to let doctors compete. Bad performers will be known and people will just stop going there. All government can do is allow poor performers to continue by removing a layer of personal responsibility by the patient to choose a good doctor. Also the feds end up taking billions out of the healthcare industry via taxes. Money that could have been used by private sector research and development of new tools and ideas that can further reduce the cost of medice. We really do not need the federal government have a hand in medicine in any way – even for providing healthcare for he poor. Private organizations and local governments provide funding as well as hopitals. Hospitals ususally have a line item where they write off emergency healthcare provided to people who could not pay.

    5. Russell Snow Idaho says:

      There is one primary and indispensable solution to healthcare costs that is ignored by most politicians: the patient must be the payer for his/her own healthcare. Insurers should no longer be allowed to send payment directly to physicians or hospitals. Yes, this would create new collections responsibilities for providers. However, restoration of individual responsibility and knowledge of one's own healthcare costs introduces immediate and widespread point-of-service cost containment. Each patient decides what care they need or want. What they are willing to pay and the extent of care they desire. Federal programs pay too little for care, barely covering overhead or with a small profit margin. The Medicaid and Medicare recipient will need limits placed on the dollar-amount of care the individual can consume over unit of time.

      This one step would virtually solve all financial problems with American healthcare.

    6. Pingback: Salvatori Prize Goes to Founder of Doctors Group | The Foundry

    7. Guest says:

      Tax Relief and HealthCare Act (TRHCA) passed by House & Senate, signed into Law by President Bush on Dec 20, 2006. This began the Pay for Performance, and healthcare quality initiatives. I don't think healthcare should be a political issue, it should be a right. Corporations use techniques such as P4P to improve quality and satisfaction with their customers, why should we not do this in the healthcare system? When I go to my doctor, I want to know that he is actively monitoring my health, and ensuring measures are taken to prevent me from becoming more ill if I have a disease. This saves the tax payers $$$. I think we should all be for saving $$$.

    8. megan says:

      As a nurse, I have to tell you, the pay for performance scheme with Medicare is only going to hurt the care given in the hospitals and further distance patients from a respectful relationship with their doctors. Patients have rights- right to be informed about their care, to expect that a doctor is treating them and their disease process to the utmost of their abilities. That being said, doctors, nurses and hospital staff are people too, and we have rights as well. We have licenses that provide the very basis of our profession, that we have spent years of effort and multiple thousands of dollars on to be able to care for you. We have a right to expect patients to be respectful towards us in manner and conversation, to be an active participant in your care, to advocate for yourself, to be compliant with the rules of the institution (i.e. no smoking the bathrooms, so juvenile, ask for a freakin' patch), to respect (even if it is to respectfully disagree with) our care and treatment of you, and to understand that we are generally working with multiple patients, some sicker than you, some not. Please do not let the fact that I took 10 minutes to get your coffee sour your whole hospital stay. see part 2…

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