by David Goldschmid, MD

From: San Mateo County Medical Association Bulletin, Nov-Dec 2006

Pay for performance. It sounds pretty cool. It sounds like a great idea. Who could say no? You can only imagine hearing Borat say something such as “I like.” There are a couple of issues that strike me as strange though. So why has it taken so long to approve the concept of payment for performance? I may be wrong, but if the federal government is advocating that physicians get paid for performance, I for one am owed big time for past performance for which I have not gotten paid.

If we are to be paid for performance, then when do I get my check? If we are to be paid for performance, then why is it that I do not get paid when I am awakened in the middle of the night to answer a patient’s questions over the telephone? Why is it that a surgeon can peer into the bowels of a human being in a procedure that results in the removal of a part of that person and get paid about as much as the cost of a good meal? Is that payment for performance?

Why is it that I must work on holidays and weekends tending to the Medicare-worried well (some of whom earn far more than I do) for less payment than my plumber or veterinarian? Is that payment for performance? Why is it that when I come in to see a critically ill patient in the middle of the night to snatch the patient from the jaws of death, the value of my payment seems less than the value of my sleep?

I want to get paid for performance. I am ready to get paid for performance and will be happy to issue a large past-due bill for the many times I performed but have not gotten paid.

Somehow, I doubt that the government has the honest notion that we should actually get paid for performance. Sometimes the message we get from our politicians is confusing. So what do you suppose this is all really about? Maybe they mean they want to sometimes pay us for performing a particular task in a particular manner. I think that is really what they mean. We should ask them to rename the program. “Payment for doing a few things we want in the manner we want, when we want, if you can prove that you did it in the way we want you to prove it.” Doesn’t sound as catchy, but seems more accurate.

In the end, payment for performance as a government initiative seems impossible to believe. After all, who in the government gets paid for performance? Well maybe the ones who put on a good show. Maybe we are completely off the mark in trying to understand what the government wants us to do. The dictionary defines performance in several different ways. Maybe we have misinterpreted what the government really wants. The dictionary defines “performance” as the act of presenting a play or a piece of music or other entertainment; “we congratulated him on his performance at the rehearsal;” “an inspired performance of Mozart’s C minor concerto.”

When we see a patient we are actually performing or acting in a manner. When I see the literature on patient satisfaction it seems to reinforce the notion that we are performing for the patient. Our behavior, movements, words, facial expressions profoundly influence what our patients think about us. Maybe the government means that our performances have not been very good, and we need to improve on the ballet we dance with the patient when we deliver care. Maybe they will pay us for a good performance, like they do themselves. Well, seems very confusing to me.

I think that no one really means they intend to pay us for performance for good medical care. I think perhaps they will be paying us for putting on a good show. Their constituents might believe they are finally doing something real to improve care. More likely, this is a way to find more reasons not to pay for care. That is something Medicare is pretty good at and finding new ways to get better. We need to stop pretending that this program is actually a clever way of improving medical care and expose the truth. We need to expose the real goals of “pay for performance,” and we need to demand that we actually get reasonable pay for reasonable care.

www.smcma.org
David Goldsmith is SMCMA President.