Medical Device Daily Washington Editor

BOSTON – The second day of the fourth annual Leadership Summit on Healthcare Quality & Pay-For-Performance commenced with a session that addressed incentives, physician engagement and public disclosure, moderated by Michael Millenson, a visiting scholar at the Kellogg School of Management at Northwestern University (Evanston, Illinois).

Six panelists with varying perspectives joined Millen-son on the dais, including Troyen Brennan, MD, now the chief medical officer for Aetna (Hartford, Connecticut). Brennan's early studies on medical errors formed the basis for the well-known 1999 report on medical errors by the Institute of Medicine (Washington).

Millenson said that he believes that “P4P is the last, best chance for American medicine to get it right” before healthcare ends up buried in “regulation, litigation and legislation.”

R. Adams Dudley, associate professor of medicine and health policy at the University of California San Francisco , said he is of the opinion that when it comes to physician behavior, “even small incentives work very well” if they are not tied to a disproportionate amount of work.

However, past efforts to improve the quality of care in the U.S. have been pockmarked by confusion and misinterpretation, Dudley said. He said that he is impressed with “how often brilliant people can get it stunningly wrong” – using capitation as an example.

This fixed-fee-per-patient system for treatment of a group of patients was not utterly flawed as is commonly assumed, but might have worked if properly deployed, he said, explaining that capitation was flawed largely because it made providers responsible for downstream costs over which the initial provider had no control.

Dudley said that incentives also can be structured in a way that is murky at best. His employer has given him incentives “off and on for five years, and I still don't know what they're for.” And any incentives would have to have physician buy-in before they could be expected to shape medical practice.

Jeffrey Kang, MD, chief medical officer at CIGNA (Philadelphia), said health plans genuinely believe that incentives work, but they are concerned about perversion of those incentives. For instance, he insisted that employers would have to get past the tendency to base their purchasing decisions on the question, “How low can we get unit [coverage] cost?”

Kang advocated the development of just one report card for providers, stating that “it makes no sense” to promulgate a number of report cards, especially given that most non-HMO practices have to do business with more than one payer and hence are subject to several standards of reporting and of quality.

He recommended that state governments or the federal government take up the task of putting together such a report card.

Kang insisted that “health plans should not be in the report card business” and that “you would see a dramatic movement toward P4P” if this type of reporting was handled by the public sector.

Brennan suggested that with each change to the system of physician compensation, babies go out with the bathwater. “We swing from one thing to another,” he said, without retaining the positive elements of the system to be jettisoned.

“I'm very much in favor of market incentives,” Brennan said, emphasizing patient commitment as key. And he urged stakeholders to bear in mind the need for sophistication “about how we drop incentives into the healthcare system.”

Evidence-based medical practice is making headway in the norms of medical practice, but “there are devils in the details,” he noted, citing problems with risk adjustment that physicians have not found a way to incorporate into their daily work despite mounds of published data.

Bruce Bagley, MD, medical director of quality improvement at the American Academy of Family Physicians (Leawood, Kansas), said that, by and large, the “culture in medicine is where I went to school,” which does not “tell you anything about what I do” day-to-day.

Bagley said that there is good news from his association. About 30% of members report that their records are electronic and that the figure should be up to 40% in a year, although this is more meaningful, thus far, in terms of chart retrieval than in care analysis.

The typical general practitioner, he said, feels that risk assessment is suspect and thinks that “all my patients look like my sickest patient.” However, a bell-shaped curve most likely represents the reality of most practices.

As for best practices, Bagley reminded the audience that “if you have the right measures, the answer is always 100% right,” but the data do not cover all scenarios and co-morbidities, so the optimal treatment regime is not always known.

Donald Fisher, PhD, president and CEO of the American Medical Group Association (AMGA; Alexandria, Virginia), said, “we don't think P4P goes far enough.” He derided the current batch of incentives as templates of practice having more to do with physician behavior than with outcomes. AMGA is of the opinion that “we need to incentivize patients as well as doctors.”

He described P4P as “a good first step that we can't be satisfied with for long,” advocating a results-based system that would focus “on outcomes, not just systems and processes.”

Bagley told Medical Device Daily that getting providers to look at the individual patient's outcome is an essential ingredient, especially given that medical resources are limited. In reference to an earlier comment on an alleged overuse of coronary stents, he noted that “there has to be a balance” between treating patient A aggressively and not using resources that might be better applied to patient B.

He acknowledged that the pressure to link general and specialty practices could lead to consolidation in the provider end of the healthcare industry, but that such a prospect is not necessarily problematic “if this is done for the right reasons” – such as to provide better service rather than simply for bargaining power with payers and suppliers.