Wednesday, February 1, 2012


What a great concept. You work hard and your hard work gets you a reward. An ideal concept, so simple and above reproach, you would think?

The pay part of the first “P” has no ambiguity-laden vices in it. You pay for what you get. Determine the benefit, write the check and the transaction is complete. Also quite simple!

Now here comes the quasi-deterministic, difficult to interpret non-equitable half of that three-lettered bureaucracy. How in the world do you determine the right-sided “P?” Indeed, How?

In medicine where the recipients of all the benefits of the medical world come in all shapes and sizes, the world of “equating” falls apart at the seams.

In medicine the “performance” is determined by the outcome of the patient. Simplistically speaking if some one comes in with a cold and you prescribe a medicine and the cold, heals itself, then you have performed admirably. Similarly if someone has a broken bone and it is “”plated,” “screwed.” or put in a cast and it heals itself, great you deserve an “A” for effort and oodles of reimbursement. On the other hand if someone has diabetes, a bad heart, poor blood flow in the extremities and after surgery for a minor ailment ends up with an uncontrolled infection due to poor immunity or poor self-care then you as a doctor deserve the bane of all the high-brows that determine policy. There is equal blame to go around in all aspects of those providing care.

So what do you do?

Now here is the other side of it. Physicians being physicians, are not all dumb in their quest to please the world of mega-dictates. As many have found out and determined through the process is that to “turf” the difficult patients to the secondary centers is the right course of action. This, to avoid the difficulties of the management of a oor-health patient and also to avoid the ‘stripe’ on your ever-burgeoning’ report card being formulated by the various Insurance and governmental agencies. Consequently the burden of the secondary centers increased exponentially within a short period of time. These secondary centers got jammed with the so-called “poor-performing” patients and brought down the “grades” of those institutions. And it doesn’t end there. The “secondary institutions” realized the “musical-chairs” scenario and kicked the can down the to the “tertiary centers.” The short straw was passed down-stream.

A while ago, as the story goes, a patient went to his primary care physician, who after thoughtful analysis and reasoning, referred him to a specialist. The specialist seeing the multiple co-morbid states in the patient and the likelihood of extensive time-consuming discussions involving the patient, the insurance company and the family of the patient in the future, referred him to the secondary center. The expert at the secondary center also on the hospital committee for excellence balanced his responsibility by referring the patient to a tertiary center for a “trial-based-treatment” that was not considered, leading the patient back after three months to his primary care physician, who sent the patient back to his first specialist. Given the problems in the case, he (the specialist) elected to decline care and advised other specialists in the area. The patient finally received his treatment and fortunately for him did well. But the lingering aroma of the decision-making process still stinks up the brain.

If you haven’t figured this scheme out by now, the end result was that those smart and adept in this game of “kick-the-can-down-the-road” make out like bandits for their “performance” whilst those saddled with the burden of difficult patients get the short straw.

Equally in the dog house another logical yet flawed concept of disincentives for ‘never-event” coined by the Infectious Disease experts is coming back to roost on the hospital’s nest eggs. The better term here would be NP4PP (No pay for poor performance) Poor performance being considered an “acquired” infection in the hospital. Ludicrous as it seems, it is bloated with the eddies within currents of thought flow from the towers of power. If on admission to the hospital the Emergency Room doctor did not mention there was a possibility of an infection,such as say a subclinical bacterial, parasitic, viral organism, then that is considered "Hospital Acquired." Dumb! you say? Think again. That is the mandate. This is a verisimilitude to the financial disaster engulfing the globe. Pay for stupidity and gaming the system while withholding for innovation and hard work.

Now let me transliterate this situation to a very heady, “Quant-ified” scheme that pervaded the world of finance. The similarities are eerily similar.

In the financial world derivatives are nothing more than leveraged securities of an underlying asset. 

What brought down the financial house of cards was that the “Whiz-kids” decided to bundle up different mortgagees of varying rated-value and placed them in “tranches” and sold them as securities with “first-lien” (the 25%) getting the collateral backing of the assets and the “second-liens” of which there were the 75% ers were unsecured.

 If the entire mortgage backed security was “called” or the tranche was filled with poor asset backed mortgages (You know the people who were earning $30-40,000 per annum and were given mortgages for houses worth $400,000) the poor ‘joe-shmoes” hedge-fund suckered investors would be left holding the bag of worthless paper. 

The scheme worked for a while as all such schemes do. But then someone or all have to take the fall of this “Ponzi-style-scheme.” Now what does this have to do with the P4P for physicians?  Elementary my dear, elementary! Think!

Continue the thinking, dear reader, of sending the difficult patients to the other centers. And as a “bone” so these institutions don’t get wise to you quickly, you throw in a better outcome patient. That is the same as bundling different scenarios in a “tranche,” isn’t it? Eventually, one of two outcomes have to happen; 1. The secondary and tertiary centers become wise and stop the inflow as they realize the worth of their hemorrhaging financial sheets or 2. if they don’t they lose solvency. The second scenario can be averted temporarily by a white knight, who can right the ship with hard decisions and cut the inflow of “poor-performing” patients to balance the sheet. But you might ask what happens to the sick people who need the real help and the expertise? Ah! But the “experts” have promulgated another policy of how to deal with the really sick… (convince the public the art of elegant dying) but that we will leave for another day.

The American College of Physicians Ethics expressed it’s concern: Pay-for-performance initiatives that provide incentives for good performance on a few specific elements of a single disease or condition may lead to neglect of other, potentially more important elements of care for that condition or a co-morbid condition. The elderly patient with multiple chronic conditions is especially vulnerable to this unwanted effect of powerful incentives.

Unintended consequences of well-intentioned self-gratifying enacted concepts without the foresight of seeing the horizon can be devastating. The financial markets have been reeling under the weight of the “well-meaning housing and a white picket fence for all with cheap money” scheme that may take years to deleverage. The quality of life for millions is in shambles, while in medicine the color of the swan is turning black as we speak.

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