Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

How will pay for performance ultimately impact the quality of care?

Thomas Santo, MD
Policy
January 25, 2013
Share
Tweet
Share

“Pay for performance” made headlines again this week, when Health and Hospitals Corporation (HHC), the multi-billion dollar corporation which operates New York City’s public hospitals, announced that they will be linking physician reimbursement to pre-determined “quality” metrics and patient satisfaction scores.

This announcement comes quickly on the heels of details recently released by the Centers for Medicare and Medicaid Services (CMS) regarding its first Medicare payment adjustment to hospitals under the Hospital Value-Based Purchasing Program. The program, a main tenet of the Patient Protection and Affordable Care Act (ObamaCare), withheld or rewarded up to 1% of a hospital’s Medicare reimbursement based on how they performed on quality and patient satisfaction measures, the same measures now being used by HHC.

Overall, the CMS program is the first glimpse at the shift towards “pay-for-performance” under the new health law. This is an attempt by the government to move away from the current fee-for-service model, which compensates physicians for each service provided – a model that some believe provides incentive for doctors to perform an excessive number of unnecessary tests and procedures. Piggybacking on the outcomes measures developed as part of CMS’ new program, HHC has quickly linked performance on these federal benchmarks to the salaries of their physician employees.

While the CMS program does not yet directly impact the individual practicing physician, they will be included in a similar program, starting in 2015 for the largest group practices, and in 2017 for all practicing physicians in the United States. At that time, physicians’ Medicare reimbursement is going to be directly tied to how well they meet treatment benchmarks, how much it costs them to do so, and how patients perceive the care they received (again, through post-treatment satisfaction surveys). The list of benchmarks is extensive, and includes everything from how often you prescribe steroids for chronic lung disease (when appropriate), to how often you obtain blood samples in diabetics, to the number of times your patients went to the emergency room.  Each physician will receive a report from CMS, which breaks down their performance, and highlights where they stand in comparison to their peers. Those that provide the cheapest care, while meeting the highest pre-set standards, will be reimbursed the most. Sounds simple right?

My hospital, with almost 1.5% of our Medicare reimbursement withheld (including a penalty for a high 30-day hospital readmission rate), was one of the bigger losers under the new Value-Based Purchasing program (according to a Kaiser Health News analysis). The CMS report was covered extensively in health policy circles, and I am certain received due attention in hospital and insurance company executive offices. The shocking thing was, physicians at work were not talking about it.  I don’t think it is because nobody cares, it just seems to me that many cannot find the time to stay up to date on the “peripheral” subjects of medicine, such as health care policy and health care technology (EMR, apps, digital doctors, etc), as well as remain well-read on the newest advances in disease prevention, diagnosis, treatment, etc. At times, it seems that an MPH or MBA would be as useful to operate efficiently in the current health care environment as a medical license.

Clearly, the practice of medicine, perhaps better described as the delivery of healthcare, is undergoing a radical, permanent change, at least for the foreseeable future. After all, we are only a few weeks into the first year of ObamaCare, and already HHC, one of the largest hospital corporations in the country, has decided to hold their physician employees financially responsible for the mandatory changes outlined by CMS. The complexity of these changes makes their adoption into current practice a daunting task for many physicians.

The simple fact is, that the future of medicine looks very different than it did when many of today’s doctors started medical school, even for those who have graduated in recent years.  For those who entered the field to treat patients, cure disease and make a real difference in the lives of others, the current tasks that consume much of their time and energy are carrying them further and further away from that goal. The optimists in the field would like to believe that pay-for-performance is simply a resetting of the status quo, which will take considerable time and effort, but ultimately benefit our profession and our patients in the long term.

I am hesitant to agree with this view for two reasons, among others. First, I believe that many physicians are already at or near capacity in terms of their ability to deliver care, both in terms of organizational resources, and personal time and energy. Many individual and small-group practices simply do not have the resources to understand and implement the constantly changing mandates from CMS. Therefore, when you hand them a forever evolving checklist of arbitrary measures that they must follow in order to be reimbursed properly, you only increase confusion and frustration, and do little to impact productivity or foster a system that delivers better care.

Secondly, for any physician who sees their reimbursement cut by providing “sub-optimal care”, as deemed by CMS, what is to stop them from refusing to serve their sickest, most chronically ill and frequently hospitalized patients? In so doing, they raise the “quality” of care they provide, and lower the cost at the same time (they will not be responsible for those sick patients when CMS evaluates them the next year). Such a reaction to pay-for-performance would only further accelerate a current trend in medicine, which is seeing many physicians refuse to accept new Medicare patients.

It is impossible to forecast how pay-for-performance will ultimately impact the quality of care we provide, and the cost at which we do so.  But one thing is certain; the job of physicians providing that care becomes more difficult every day.

Thomas Santo is a physician who blogs at Scope of Medicine.

Prev

Just: A word that I've resented since leaving clinical medicine

January 25, 2013 Kevin 13
…
Next

The culture of ruling out leads to misdiagnosis

January 25, 2013 Kevin 16
…

Tagged as: Medicare, Public Health & Policy

Post navigation

< Previous Post
Just: A word that I've resented since leaving clinical medicine
Next Post >
The culture of ruling out leads to misdiagnosis

ADVERTISEMENT

More by Thomas Santo, MD

  • How the Oregon Medicaid experiment is a failure

    Thomas Santo, MD
  • a desk with keyboard and ipad with the kevinmd logo

    Why digital health tools need to be rated

    Thomas Santo, MD

More in Policy

  • Bundled payments in Medicare: Will fixed pricing reshape surgery costs?

    AMA Committee on Economics and Quality in Medicine, Medical Student Section
  • Who gets to be well in America: Immigrant health is on the line

    Joshua Vasquez, MD
  • Online eye exams spark legal battle over health care access

    Joshua Windham, JD and Daryl James
  • The One Big Beautiful Bill and the fragile heart of rural health care

    Holland Haynie, MD
  • Why health care leaders fail at execution—and how to fix it

    Dave Cummings, RN
  • Healing the doctor-patient relationship by attacking administrative inefficiencies

    Allen Fredrickson
  • Most Popular

  • Past Week

    • Who gets to be well in America: Immigrant health is on the line

      Joshua Vasquez, MD | Policy
    • Why specialist pain clinics and addiction treatment services require strong primary care

      Olumuyiwa Bamgbade, MD | Conditions
    • Why peer support can save lives in high-pressure medical careers

      Maire Daugharty, MD | Conditions
    • When a medical office sublease turns into a legal nightmare

      Ralph Messo, DO | Physician
    • How early meetings and after-hours events penalize physician-mothers

      Samira Jeimy, MD, PhD and Menaka Pai, MD | Physician
    • FDA delays could end vital treatment for rare disease patients

      GJ van Londen, MD | Meds
  • Past 6 Months

    • Forced voicemail and diagnosis codes are endangering patient access to medications

      Arthur Lazarus, MD, MBA | Meds
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy
    • Who gets to be well in America: Immigrant health is on the line

      Joshua Vasquez, MD | Policy
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
  • Recent Posts

    • Harassment and overreach are driving physicians to quit

      Olumuyiwa Bamgbade, MD | Physician
    • Why regular exercise is the best prescription for lifelong health

      George F. Smith, MD | Conditions
    • When the weight won’t budge: the hidden physiology of grief, stress, and set point

      Sarah White, APRN | Conditions
    • Why starting with why can transform your medical practice

      Neil Baum, MD | Physician
    • Why your most heroic act might be in a department meeting [PODCAST]

      The Podcast by KevinMD | Podcast
    • Life’s detours may be blessings in disguise

      Osmund Agbo, MD | Physician

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 7 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

  • Most Popular

  • Past Week

    • Who gets to be well in America: Immigrant health is on the line

      Joshua Vasquez, MD | Policy
    • Why specialist pain clinics and addiction treatment services require strong primary care

      Olumuyiwa Bamgbade, MD | Conditions
    • Why peer support can save lives in high-pressure medical careers

      Maire Daugharty, MD | Conditions
    • When a medical office sublease turns into a legal nightmare

      Ralph Messo, DO | Physician
    • How early meetings and after-hours events penalize physician-mothers

      Samira Jeimy, MD, PhD and Menaka Pai, MD | Physician
    • FDA delays could end vital treatment for rare disease patients

      GJ van Londen, MD | Meds
  • Past 6 Months

    • Forced voicemail and diagnosis codes are endangering patient access to medications

      Arthur Lazarus, MD, MBA | Meds
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy
    • Who gets to be well in America: Immigrant health is on the line

      Joshua Vasquez, MD | Policy
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
  • Recent Posts

    • Harassment and overreach are driving physicians to quit

      Olumuyiwa Bamgbade, MD | Physician
    • Why regular exercise is the best prescription for lifelong health

      George F. Smith, MD | Conditions
    • When the weight won’t budge: the hidden physiology of grief, stress, and set point

      Sarah White, APRN | Conditions
    • Why starting with why can transform your medical practice

      Neil Baum, MD | Physician
    • Why your most heroic act might be in a department meeting [PODCAST]

      The Podcast by KevinMD | Podcast
    • Life’s detours may be blessings in disguise

      Osmund Agbo, MD | Physician

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

How will pay for performance ultimately impact the quality of care?
7 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...