Pay for Performance

In the President’s Point of View column of Santa Barbara County Medical Society’s Medical Society News of July/August 2005, Dennis H. Baker, M.D., wrote:

“In 1999, when the Institute of Medicine published its reports, ‘To Err is Human’ and ‘Crossing the Quality Chasm’ pointing out the high prevalence of medical errors. Since then, policymakers at all levels have been looking for ways to repair the situation where, it is said, tens of thousands die unnecessarily and where billions of dollars are lost each year due to mistakes made in hospital and outpatient settings. While many argue the basis and methodologies used for these figures, the fact is there are wide variations in the quality of care provided in this country and, that efforts to remedy the situation can save valuable lives and resources.

“Clearly, the leadership for these efforts must come from medicine itself. Only the profession and its physician leaders can properly balance the factors that directly impact quality and cost of care. Leaving this work to payers or the government will only result in harm to patients, physicians, and the profession of medicine. It is increasingly likely that the federal government will soon mandate performance measurement and payment for quality performance. Called ‘pay for performance’ (P4P), or as it is known in proposals on Capitol Hill, ‘value based purchasing’ would tie Medicare payment to physicians to objective measures of improvement in the quality of care we provide.”

To read more of this article, go to www.sbmed.org/webpages/publications.asp.

Legislators: Quit Practicing Medicine

In his “Mert’s Musings” in the Fresno-Madera Medical Society’s Vital Signs, Executive Director Mert Scholten wroteto legislators:

“Quit trying to practice medicine! OK, So you don‘t really practice medicine, but many of the decisions you make on legislation proposed (and too often adopted) have a direct influence on the way in which medicine is practiced. And that may not be good for either patients or doctors.

“A case in point: requiring 12 hours of continuing medical education in pain management for virtually all physicians other than pathologists, anesthesiologists, and radiologists. This law grew out of a professional liability, case wherein the family of a dying, patient charged that the doctor did not properly manage the gentleman’s pain though the patient himself did not seek additional pain relief nor complain that his pain was unbearable.”

Read more at www.fmms.org/default.asp (membership required).

As physicians, we well know that simply seeing a loved one in bed and maybe even unconscious causes the family member more pain than the patient is experiencing, just as in the example that precipitated this unconscionable law. The rest of the article details the downside of legislators practicing medicine without a license and how it harms both physicians and patients. Physicians are well able to determine their Continuing Medical Education (CME) needs. Should the legislators that voted for this law be prosecuted for this offense of making medical decisions without a medical license? They are not experts in medicine; it seems difficult to find any field in which they have any expertise.

While legislators reduce us and our practice to hard facts, we would do well to remember a comment in last month’sMars Hill Audio Journal: Twenty years ago, writing in The Wilson Quarterly, the literary critic Cleanth Brooks noted that: “A world reduced to hard facts would thereby become a dehumanized world, a world in which few of us would want to live. We are intensely interested in how our fellow human beings behave — in their actions, to be sure, but also in the feelings, motives, purposes that lead them into these actions.” In this case, even the facts were not factual.

Medicine and Sex: A top 5 list

In the Humboldt-Del Norte County Medical Society Bulletin, Luther F. Cobb, MD, started The President’s Message: with a one-word headline: SEX. He continued:

“Now that I have your attention, it occurs to me that there are several similarities between the average American’s attitudes toward sex, and their attitudes toward medical care. In the spirit of David Letterman’s famous Top Ten list, I offer my modest version of a Top Five list on the subject.

“REASON #5. Although not everybody is interested at all times in getting some, at certain critical points of their lives it becomes a very prominent concern.

“REASON #4 Most Americans believe that obtaining it is a basic human right, to which they are entitled just for being here.

“REASON #3 Most Americans agree that their usual and customary provider doesn’t give frequent enough, prompt enough, or good enough quality service.

“REASON #2 Many people think to get the exotic, high-tech, cutting-edge level of service they have to leave town, but they’re often disappointed to find once it’s over that the attention received was a lot less personal.

“AND THE #1 REASON IS:

“People think it’s a sin to pay for it.

“While the above is definitely offered in the spirit of good humor, it does occur to me that it’s a lot more truth than joke. We really do have a different attitude in this country toward medical care than we do about any other economic enterprise, other than warfare. There is a serious disconnect… “

Affordable Health Care

Internist Mark K. Belknap, MD, President of the Wisconsin Medical Society, argued that society must lead the way in reforming health care. He used this example in his article:

“A 50-year-old female convenience store manager from the Upper Peninsula of Michigan was recently referred to me from the emergency department (ED) for evaluation of heart failure. She had presented to the ED with progressively severe shortness of breath and leg edema. She had no health care insurance and had not seen a physician for several years. Following an episode of rheumatic fever as a teenager, she had a history of a murmur. An echocardiogram was performed, and it showed severe mitral stenosis and severe pulmonary hypertension. I referred her for cardiac catheterization, which confirmed the findings of the echocardiogram, and she underwent mitral valve replacement. Several aspects of this patient’s case are typical in patients without health insurance. Because she had no personal physician, she initially presented to the ED, where care is much more expensive. Her costs exceeded $60,000 and she has since applied for “compassionate care.” She presented at an advanced stage of her disease because she had not had regular ongoing health care. It is likely that she developed rheumatic fever and, subsequently, mitral valve disease because of lack of access to care for her initial episode of streptococcal pharyngitis. As a consequence of her need for mitral valve replacement, she will need lifelong anticoagulation with warfarin, with its attendant cost and risks. It is uncertain at this point how much of her pulmonary hypertension is reversible, and she may continue to suffer the morbidity of this condition because she did not receive care in a timely manner.”