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Letters to the Editor  |   August 2008
Eliminating Bad, Bad Medicine: Problems With P4P Initiatives
Author Affiliations
  • Richard McDonald, JD, PhD
    GenoVar Diagnostic Pahrump, Nev
    Senior Principal Scientist Product Development Associate Director
Article Information
Practice Management
Letters to the Editor   |   August 2008
Eliminating Bad, Bad Medicine: Problems With P4P Initiatives
The Journal of the American Osteopathic Association, August 2008, Vol. 108, 465-468. doi:10.7556/jaoa.2008.108.8.465
The Journal of the American Osteopathic Association, August 2008, Vol. 108, 465-468. doi:10.7556/jaoa.2008.108.8.465
To the Editor:  
The special communication by Robert G. Locke, DO, and Malathi Srinivasan, MD,1 about pay-for-performance (P4P) initiatives, in the January issue of JAOA—The Journal of the American Osteopathic Association was thought-provoking. I believe, from a patient's perspective, that aspects of P4P initiatives may seem useful, but I question their application in actual clinical practice. 
For example, the P4P initiatives, on paper at least, may seem helpful for certain practices, such as those with clinics that are operated as “cattle calls” (ie, “fast-food medicine”); those with physicians who have terrible people skills (ie, bad bedside manner); those that re-use syringes2; and those with physicians and other healthcare providers who fail to wash their hands before and after patient interactions. 
In reality, however, the P4P initiatives are not going to make “non-handwashers” suddenly start washing their hands. Hand-washing is something you learn as a student in elementary school—not as a practicing physician. Neither will the P4P initiatives make those physicians with bad bedside manner develop better people skills; these are skills that you either have or do not have prior to matriculation. 
In short, the P4P initiatives are not going to prevent bad physicians from practicing fast-food medicine, re-using syringes, or transporting patients when not medically necessary in an effort to increase “billable hours.” All those real-world situations encompass ethical issues that are learned prior to medical school. 
Furthermore, taking a yearly ethics examination before obtaining a state medical license will not change poor medical behaviors either. Efforts to eliminate “bad medicine” need to begin with recruiting efforts—and factors beyond Medical College Admission Test scores need to be considered. A written examination with the question, “True or False: Can washing your hands prior to and after seeing a patient reduce microbial spread?” is useless. That question would never weed out the non-handwasher because even a 5-year-old child would know how to answer it correctly. 
Rather than improve the behaviors of bad physicians, the P4P initiatives have the potential to create serious problems for good physicians. As a patient, I see the P4P initiatives taking away a good physician's ability to practice medicine because the initiatives may have the effect of turning practitioners into administrators—administrators who follow rules, regulations, and by-laws to the detriment of a patient's unique medical issues, or who use a one-medicine-fits-all approach. 
It is true that checklists can be very useful in any profession. For example, a report presented at the annual meeting of the American Society for Microbiology in New Orleans, La, in May 2004, showed that 46% of the neckties worn by physicians at the New York Hospital Medical Center of Queens contained large quantities of Staphylococcus aureus and other infectious microorganisms.3 Thus, one item on a useful checklist in hospitals and clinics would prevent physicians from wearing neckties. However, checklists and similar quality-improvement initiatives can be overly complicated, resulting in possible adverse effects on the quality of patient care.4 
If the P4P initiatives are intended to establish a new standard of care (as mandated checklists), why not just use a software program to fulfill the purpose of the initiatives and determine the medical necessities for each patient? 
In computerized medical assessments, patients would answer questions about their medical needs, and—based on patient responses...and the assumption that the questions were answered truthfully—the software would produce a clinical diagnosis and appropriate prescription. 
If the P4P initiatives could truly assess clinical observations, the US Food and Drug Administration (FDA) would not need expert committees to analyze preclinical, clinical, and postmarketing data on drugs and medical devices. Instead, the FDA would rely on a software program like the one described to accurately evaluate a drug or medical device based on inputted data. This hypothetical scenario, of course, is not realistic because no software program could adequately substitute for the years of practical experience represented by physicians in their clinics or on FDA expert committees. 
I agree with the majority of the DO survey respondents that P4P initiatives would not appropriately capture the quality of their work.1 Medicine is referred to as being “practiced” for a reason, and practicing medicine does not mean that every patient's medical needs are the same. In addition, the statistical significance found in an academic study may not translate usefully into a physician's private clinical practice. Conversely, an excellent patient-physician relationship will not translate into a checklist item that can be given to a poor physician to automatically change his or her terrible skills (whatever they might be) into the skills of a great physician. No P4P initiatives will change the behaviors of those physicians with questionable ethics or poor medical-business practices. 
The P4P initiatives are not grounded in the realities of clinical practice. Many physicians who practice good medicine and many hospitals that use quality-assurance checklists still have patients who test positive for infectious microorganisms, such as methicillin-resistant S. aureus (MRSA). Medicare officials recently announced that they plan to stop paying for 13 common conditions typically caused by hospital errors.5 Some of these errors can obviously be prevented, but others, such as MRSA infections, cannot. As with the P4P initiatives, Medicare's “Hospital 13” plan5 ignores the realities of clinical practice. The Medicare plan implies that all microbial infections are hospital-acquired or hospital-generated. However, this is misleading because one-third of MRSA infections are community-acquired.6 Does hospital protocol now need to dictate that all patients head toward the laboratory to get tested for MRSA before treatment—similar to the way some hospitals screen every pregnant patient for drug use? 
I also take issue with the value of the patient satisfaction scale reported in the article by Drs Locke and Srinivasan.1 Is the patient satisfaction scale, which is likely to become the cornerstone of P4P evaluations, really a true measurement of medical care quality? 
For example, how is a physician supposed to help a patient who has been diagnosed with chronic obstructive pulmonary disease but refuses to stop smoking? What about those patients who are not proactive with their healthcare, yet expect the physician to fix their problem(s) quickly with a pill? 
Presuming the physician does not “cave in” to a patient's medically irresponsible requests, the smokers and pill seekers will undoubtedly rate the physician poorly—thus skewing the results of that physician's patient satisfaction scale rating—and seek a second opinion. Obtaining a second medical opinion is not inherently bad, but seeking a second medical opinion for the wrong reasons is dangerous. 
It has been stated anecdotally that about 80% of the US healthcare budget is consumed by the effects of five behavioral issues: smoking, alcohol consumption, lack of exercise, poor nutrition, and stress.7 No P4P initiatives or Medicare-mandated payment refusals will change unhealthy patient behaviors. 
Should there then exist a report card for patient healthcare performance in which a patient's efforts at good self-care determines his or her costs for healthcare? Should this report card include factors such as how well a patient manages diseases with a genetic basis, such as type 1 diabetes mellitus? 
It needs to be kept in mind that a successful medical healthcare system consists of approximately 10% medical guidance and 90% patient effort—not the other way around. Consequently, the P4P rating system makes a huge and erroneous assumption that medical soundness takes a back seat to a patient's whims. 
Another issue highlighting the inadequacy of the P4P initiatives is related to lack of patient options. For example, there are clinics in some areas of the United States that are the only ones in town—and thus the only healthcare option for patients. Yet, some of these clinics may provide terrible healthcare. How would the P4P initiatives improve the care of patients in such clinics? 
Years ago, I went to a physician whose arrogance created a poor patient-physician relationship. As a patient, I decided to never return to that physician, regardless of the degrees and certifications displayed in his office. I now have a primary care physician—an osteopathic physician in family practice—who, from my perspective, is excellent in all aspects of clinical practice. I plan to keep her as my primary care physician even if she changes her practice location (provided that she agrees to still be my physician, of course), regardless of P4P initiatives or her patient satisfaction scale scores. 
I follow (as in the 90% patient-effort part referred to above) my physician's medical recommendations and advice (the 10% medical-guidance part) to ensure that my healthcare path is proceeding according to our plan (encompassing 100% medical healthcare). 
A mutually respectful relationship between a competent physician and a responsible patient is ultimately the only way to achieve quality healthcare. The P4P initiatives will never replace that, as they place all the responsibility on physicians and none on patients. 
Locke RG, Srinivasan M. Attitudes toward pay-for-performance initiatives among primary care osteopathic physicians in small group practices. J Am Osteopath Assoc. 2008;108:21-24. Available at: http://www.jaoa.org/cgi/content/full/108/1/21. Accessed July 31, 2008.
Thousands may be infected by Vegas clinic; March 5, 2008. USA Today Web site. Available at: http://www.usatoday.com/news/health/2008-03-05-hepatitis-vegas_N.htm?loc=interstitialskip. Accessed July 31, 2008.
A doctor's necktie can be hazardous to your health. The Caregiver's Hotline [serial online]. 2004;1(7). Available at: http://caregiver.nowis.com/news/article.cfm?UID=172. Accessed May 15, 2008.
Kuehn BM. DHHS halts quality improvement study: policy may hamper tests of methods to improve care. JAMA. 2008;299:1005-1006.
Neegaard L. Hospitals, errors to get more expensive. Las Vegas Journal. February 19 ,2008 : 1A,5A.
Worcester S. Chicago-area hospital system takes on MRSA. Ob Gyn News [serial online]. 2005;40(18):19. Available at: http://download.journals.elsevierhealth.com/pdfs/journals/0029-7437/PIIS0029743705710302.pdf. Accessed July 31, 2008.
Deutschman A. Change or die. Fast Company [serial online]. May 2005(94). Available at: http://www.fastcompany.com/magazine/94/open_change-or-die.html. Accessed July 31, 2008.