Ending the Disruption of Pay for Performance


It is hard to stop a Bandwagon, but a Bandwagon rolling the wrong way needs to come to a halt. Pay for Performance has had its 15 years, and has been found lacking. 

“In summary, we found low-strength, contradictory evidence that P4P programs could improve processes of care, but we found no clearevidence to suggest that they improve patient outcomes.” from The Effects of Pay-for-Performance Programs on Health,Health Care Use, and Processes of Care: A Systematic Review, Annals of InternalMedicine 1/10/17. 

This was more than just an article. It was a comprehensive review. Even more important, the studies reviewed were written by authors that in the large part wanted to demonstrate the benefits from pay for performance. Despite the best intentions, pay for performance has fallen short. 

Those immersed in P4P and value based design will have to make some difficult choices. Resistance is likely. This also will delay what must happen. What must happen is a move away from disruption of those who deliver care, especially care where needed.

There is even hope for some peace to return. Common sense, awareness, and the literature all agree This hope is the result of the Annals of Internal Medicine article, or actually the dozens of studies represented.


In the Age of Untruth There Can Be a Return of Hope... 

There is hope of a return to health care delivery focus rather than disruptive change for those who deliver the care. There is hope of a removal of payment designs that are disruptive for those who deliver care where most needed. There is hope for an end to payment discrimination as well. There is hope for a focus on true payment reform or more dollars to services falling most behind (primary care, mental health, basic services) - a treatment for American health care delayed for decades and another decade by pay for performance and insurance focus.

The Necessary Transformation in Health Care Improvement

This does not mean that improvements are not needed in health care delivery. What it does mean is that we should put an end to the “us vs them” divisions that have arisen as those not delivering health care have hounded those delivering health care to do more while providing less support as patients and their situations have grown ever more complex.

There should be an end to top down driven health care changes. There should be a return to ground up changes driven by the full awareness of what is going on at the patient, family, community, population, and local levels.


A New Beginning for Health Leaders or Health Leaders Moved On and Out

The evidence should signal a change in the decisions of health care leaders or a departure from leadership. Many physician association leaders have hoped in vain for a change to more payment via value-based payments. Experts have long been astounded that family medicine leaders would embrace payment changes certain to compromise family physicians. Now the evidence is clear. Performance based payments are demonstrated as costly and not capable of discerning quality or promoting value.


Perhaps even family medicine leaders will be forced to accept the evidence regarding P4P failure and P4P discrimination against hospitals, physicians, clinics, and others caring for the underserved, rural populations, lower concentration county populations, and others associated with lesser outcomes and therefore lesser payments by design. 

FM leadership must recover from poor decisions in the past year:
  • Pay for Performance Is Not a Route to a Better Financial Design
  • Pay for Performance Was Never a Route to Better Payment Where Most Family Physicians Are Found - Where FM Is Most Needed Where P4P and Other Designs Pay Less to Least Already (Six Degrees)
  • Pay for Performance Is Lacking in Evidence Basis
  • Board Certification Activities Are Lacking in Evidence Basis
There Must Be No Additional and Unnecessary Delays in the Necessary Improvements in the Financial Design, a Requirement for  
  • More team members and better supported team members in more places to actually recover primary care and mental health access
  • Stable or increasing retention in primary care for primary care graduates
  • The only route to solutions for health access
The bigger question is a most important one, “Will we avoid disruptive and unproven changes in health care now that we have had the consequences of two major disruptions?”


Lesson 1 Regarding Payment Designs Without Evidence Basis - the Deadly and Disruptive DRGs and Prospective Payment

Desperate politicians desired to shift dollars away from domestic spending to ramp up military spending. Health care was a huge and rapidly increasing cost. DRGs was the only method available for those planning domestic cost cutting in 1983. The DRG design was implemented before any reasonable study, and has been directly disruptive by focusing hospital care to new goals - rapid patient discharge, personnel cuts, and bottom line focus over patient care focus.

For thousands of hospitals, the priority became survival focus. Even so, about 700 were closed without regard to health access, local workforce deficits, or declines in local jobs, cash flow, and determinants of health.

The problems of DRGs were anticipated. There were guidelines to prevent Prospective Payment abuses that were supposed to protect patients and delivery team members but these guidelines have consistently failed because the PPS model drives the violations. 

We failed to protect the patient and the delivery team member. Even worse, we did not learn from this experimentation. We did not learn that those disconnected from delivery should not design disruptive change. Collaborative approaches should be the only approaches in something so important and so complex as health care.

Disruption Has Accelerated with Morale and Productivity Disrupted


In the last 20 years the medical error bandwagon morphed into pay for performance and value based care in ways that have been disruptive to delivery team member’s lives, functions, productivity, and morale. Focus upon disruption has been costly. These increased costs of delivery have stolen the dollars needed for more team members and better support of team members.

This second time, the disruptions have also impacted small hospitals and small practices. Once again the progress of 1965 – 1978 has been reversed.

The Requirements for Improved Health Care Are Simple, Not Complex

Steady improvements require disciplined leadership that facilitates the work at the local level specific to patients. This is where health care delivery exists. Delivery requires access to health care and health care team members. Access requires the workforce and team members. Those most distant from this understanding tend to make care too complex. 

The simple fact is that best health care is about best support of team members. Best health is about best support of communities, populations, and patients long before and long after health care encounters.

Collaborative work between all involved in health care, especially those who deliver the care, is still required for improvement. The proper focus for higher functions in hospital care and in primary care remains the support of the team members that deliver the care.

Reversing Us vs Them Disruptions Will Take Time, Talent, and Treasure

Disruptions have been seen most by patients lacking access. Many in America feel betrayed by health care. It has not helped that many have been told that they have marginal health care providers. These ratings are now known to lack proper controls for the fact that low rated providers care for the most complex with the least resources.
Change is costly and chaotic, disruptive change is costly in more ways. Changing to one design and back to another is wasteful and most disruptive. When designs are implemented for the wrong reasons and without the proper study, disruptions are very costly.

Disruptions between delivery team members and administrators/bureaucrats will take time to heal also. The "us vs them" mentality may always be present to some degree, but this should not dominate relationships and should not prevent collaborative work.
Collaborative work with patients and populations is required and delivery team members translate this process and activate it. It is the primary task of administration, management, government agencies, and insurance companies to facilitate the efforts of delivery team members.


The Lessons of Health Care Payment History 
There are important questions to ask so that history teaches us important lessons. There was once more control and influence exerted by those who deliver care.

  • Why did we ever turn the design over to those disconnected from care delivery? 
  • Why did we allow those disconnected from the complexity of human beings to take over?
  • Why did we tolerate the abuses of those too connected to numbers and spreadsheets to dictate cost cutting – cuts that we knew would compromise care and patient outcomes? 
  • Why did we allow researchers and others too connected to the simplicity of numbers and regressions to dictate patient care and payment designs?


Human Complexity Is Beyond Human Measurement Capacity
 
Once again humans are demonstrated to be too complex, especially in the health care components involving humans. Hong demonstrated this in his JAMA article regarding the discrimination of pay for performance against the underserved.
The measurement process requires too much multilayered complexity to comprehend. There are just too many variations, permutations, variable type differences, and other complexities that are specific to patients and their situations, behaviors, environments, and other determinants. The non-hospital forces shaping outcomes exist for decades before encounters, impact care during hospitalization, and impact outcomes after discharge.

It is time for peaceful supportive collaborative health care designs - not designs that disrupt the lives, jobs, and best efforts of those who deliver care.



A Return to Ethical and Moral Human Subject Experimentation in Payment Design


It is time for evidence basis to justify changes - before the changes and experimentations are implemented. Health care designs and designers should work toward transparency, informed consent, protection of vulnerable populations, and beneficent intent.

Once again the rapid adoption of policy long before evidence basis has been revealed as costly damaging human experimentation - experimentation that we should never accept in something as important as health care delivery.

Taking out costly disruptions are ways to more peaceful practice. Health care should be less war and more peace - by design.


The performance metric for risk-standardized 30-day readmission rates for MI is not associated with quality of care, long-term mortality risk, or long-term readmission risk beyond the first 30 days following discharge.

Pay-for-performance programs may be associated with improved processes of care in ambulatory settings, but consistently positive associations with improved health outcomes have not been demonstrated in any setting.

Pay for Performance has failed to deliver on promised outcomes, has driven up the cost of delivery, has added distractions for team members, has distorted health services research, and has contributed to two forms of discrimination with regard to most needed providers. It is time for something else such as returning the focus to support for the team members that deliver the care.

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The 25th Anniversary of the COGME Third Report and No Change By Design

Why Is Value So Hard to Recognize in Health Care and why does family medicine not value family physicians and the high value places where they practice

The Four Horsemen of the Primary Care Apocalypse - Medicaid, High Deductible, Veteran, and Medicare Plans shape failure by payment design

Plea to Academic Leaders - Please No More So Called Primary Care Solutions - No Training Intervention or Practice Rearrangement Can Work without Payment Reform

What Is Stunning in Primary Care Is No Change By Design - Numerous failed attempts to recover primary care all point to insufficient payment made worse by accelerating cost of care. 

Six Degrees of Discrimination By Health Care Payment Design - Medicare payment transparency exposes Medicare as paying less for primary care, less in the states in most need of workforce, less in counties in most need of workforce, and even less with Pay for Performance designs. Also places with concentrations of patients with plans least supportive of local care receive the fewest lines of revenue and have deficits of workforce by design.

Managed Care to Dartmouth to ACA to MACRA innovators have failed to focus on the patient factor changes that could improve outcomes but the innovators have managed to change physician behavior -  the wrong way to turnover, retirement, closures of practices, larger practices, avoidance of complex patients, disengagement, lower productivity  

 Value Failure By Those Who Promote Value - Rapid change, confusing changes, costly change without outcome improvement, adverse impacts of quality measures, forced decisions for mergers or closures, failure to support most needed generalists and general surgical specialties to meet demographic changes, and greater challenges due to declining health and social resources where most Americans need care 



Robert C. Bowman, M.D.        Robert.Bowman@DignityHealth.org

The blogs represent the opinion of the blogger alone.

Copyright 2017


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