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Archived: Paying Doctors to Push Certain Meds More Common Than You Think

It has become somewhat of a yearly ritual for many American workers – anticipation of the year-end bonus. From real estate brokers to regional managers, attorneys to advertising execs, the notion that good performance on the job should be financially rewarded has become universally accepted or even expected.

Did you know that even your doctor may have received a yearly bonus for meeting certain performance measures? Under an increasingly common plan used by the Health Insurance industry called “Pay for Performance,” or P4P, doctors, medical groups and other health care providers earn monetary rewards for reaching goals designed to incentivize the delivery of certain healthcare services that promote better outcomes for patients.

The idea that physicians should be rewarded for doing their job well seems perfectly logical. But when it comes to providing medical care, the issue of bonuses under the P4P system gets a little trickier. P4P may in fact make it harder for you to find a doctor or receive certain treatments.

It’s all about how P4P bonuses are determined by the insurance companies.
Imagine you are a family practice physician participating in a P4P program and two new patients walk in your door. One is an affluent 34-year-old man, with no significant medical history, complaining about an achy knee. The other is a retired 62-year-old woman on a limited income suffering from diabetes and heart disease. If your medical group rewards you, the physician, for successful patient outcomes, which of those patients would you take? Probably not the older, unhealthy woman, right?

According to a study published in the Journal of the American Medical Association in 2007, P4P may have a detrimental impact on the populations with the highest disease burdens and the greatest healthcare disparities. The study by Rodney Hood, MD, past president of the National Medical Association, argues that there is serious concern among minority health groups that P4P actually serves as a disincentive for doctors to take on new patients with existing medical conditions. An opinion piece in the New York Times published in September aptly describes this practice as “cherry-picking” patients.

Dr. Hood also suggests that P4P will lead to significant racial disparities in terms of therapies. Studies have shown that African Americans receive far fewer preventive or diagnostic procedures such as angioplasty or hip replacement, but receive a higher percentage of limb amputations and organ removals.

Another potential pitfall lies in P4P’s incentivizing the prescription of “mandated” medicines, as the New York Times column notes. P4P programs often include an element that targets prescription medicines for cost savings without sufficient attention to outcomes. Of particular concern are arrangements wherein insurance plans incentivize doctors to prescribe a specific medicine based on cost alone or to switch patients to completely different prescriptions from those on which a patient is stabilized.

While this practice is being positioned as increasing generic medication use, it is doing so by switching to versions of medications that are different from the medications the patients are taking.  Such a practice has the potential for significant patient care problems, including adverse drug reactions, and may cause problems with patient adherence. In addition, such a practice raises concerns about a conflict of interest when a physician is paid to prescribe a medication that may or may not be in the best interest of the patient.

In spite of the concerns that have been voiced about P4P, such programs are becoming increasingly common in California and throughout the nation. In September, Blue Shield of California announced it is awarding $29.5 million in bonuses to California doctors participating in its Pay for Performance program.

While doctors should be rewarded for doing a great job, the unintended consequences of P4P have the potential to do patients more harm than good. These flaws must be addressed before any more patients’ lives are put at risk.

We must ensure that P4P is structured to reduce health disparities and improve health outcomes for all patients, regardless of their age, ethnicity, health status or income.

Let’s make sure that doctors are rewarded for improving the care of each individual patient, and not encouraged to deny, limit, or restrict care for the most vulnerable, the most costly, or the sickest patients.

Karen Vicari is  executive director of The Alliance for Better Medicine http://www.allianceforbettermedicine.org/