Thursday, February 23, 2006

New York Times on misdiagnosis: a follow up

My post about the NYT article on misdiagnosis sparked discussion by commenters and other bloggers. I wrote that pay for performance (P4P) has not been demonstrated to improve quality. An anonymous commenter said “Uh, the study DID show improved screening rates for cervical cancer (at least according to the abstract).” To elaborate: three measures, cervical cancer screening, mammography, and hemoglobin A1C measurement were analyzed. After implementation of P4P there was no difference in improvement for two of the three measures. Cervical cancer screening showed a modest difference in improvement (3.6%). Moreover most of the bonus money went to providers already above the quality thresholds at baseline, who demonstrated little improvement. I stand corrected for not having nuanced my statement about the study findings, although these data do not make a convincing case that P4P improves quality. Perhaps we can agree, at the risk of being trite, that more study is needed.

Kevin linked to my post. One of his commenters, Dr. Hebert, pointed out the absurdity of rewarding or penalizing doctors for outcomes. He said “If doctors are paid by outcome, patients that have diseases with poor prognoses, like liver cancer or spinal injuries, will find themselves unable to find a doctor.”

Hippocrates at health voices weighed in with “Fighting the public's perception that there is room for improvement in health care quality is a losing proposition, both politically and economically. Skyrocketing health care costs make demands for accountability inevitable.” Hippocrates may have missed my point. I would never argue against room for quality improvement. I was merely taking the New York Times to task for distorting the facts. Talking about incentivizing quality, the Times piece says “For a politician looking to make the often-bloodless debate over health care come alive, this is a huge opportunity.” Is the author looking for a political football or a blood bath? That’s the problem I have with this piece. Can’t we keep the health care debate sober and factual?

Hippocrates also said “Pay-for-performance is an easy concept for the public to grasp and ignoring this is an indefensible position.” Ignoring it is one thing; asking for proof is another. What’s missing from this discussion is consideration of the cost of widespread adoption of P4P with incentives that are meaningful. Once the public grasps the true cost how will they perceive it?

1 comment:

The Medical Blog Network said...

No doubt the very format and audience of New York Times ensures "dumbing down" of any issue they touch. That is the business they are in. Playing to emotions brings readership.

As a fan of Dr. RW's I am first to say his blog is the place for real thought, rather than rhetoric. Yet I think we simply looked at the same issue from two different angles, which are complementary, rather than conflicting.

It is hard to argue that "more study is needed" to make P4P really work. But more work is also needed to communicate the quality improvement & cost control measures to public in the way they would understand and accept. This is still work in progress, as I have written:

1) Pay-for-Performance: The Good, The Bad and The Ugly
2) Pay-for-Performance: Faults in Concept or Implementation?
3) American College of Physicians Proposes a Reasonable Approach

If medical community does not define the issue from consumer advocacy perspective and take the lead, then New York Times will. This includes P4P, quality, outcomes, IT, etc. etc. etc.

So here is the challenge I propose: How to communicate these ideas to public in a scientifically sound way?