Feet First

“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” - Sir William Osler

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    Tuesday, December 09, 2008

    We're deep into the madness of P4P (pay for performance) here, in case you're wondering why I haven't posted much lately. This basically means tracking down all patients who haven't had their diabetes checked/ gotten their pap smears/ had their colonoscopies/ etc. It is a huge amount of work; The Firm has a whole stable of employees who have been spending time doing nothing but referring patients to come in and get this stuff done. Why are we paying people to call patients all day?
    • We get paid to do it. Managed care insurance companies have a fund of incentive money they pay to groups (maybe to individual doctors as well? not sure) who meet their criteria. Of course they keep raising the bar, so it gets tougher every year. They also add new criteria every year - for instance, if you treat somebody with bronchitis with antibiotics now, that counts against you. (It isn't as crazy as it sounds; most bronchitis is viral and responds better to inhalers. But that's another post.)

    • The groups that do the best get good publicity. Every year the insurance companies publish their list of groups that provide the "best care." Of course this list gets lots of local publicity and winds up in the L.A. Times (for example) every year. This hopefully translates into more patients signing up with The Firm.

    I hate P4P season - we all do. Not that I'm arguing against giving people good care and getting their cholesterol down, mind you. It just seems that the goal is lost in a paper chase: The statistics count more than the patients. Also, we always have those stubborn few who won't take their cholesterol lowering meds, aren't compliant with their diabetes treatment or hate mammograms. Such patients are anathema to any good paperchasing doc. It's difficult to look at these people and not think You're ruining my numbers!, horrible as that sounds.

    I foresee a day when these patients will form a tribe of outcasts, wandering from group to group and primary care doctor to primary care doctor, staying just long enough for the "care provider" (as we will doubtless be known) to find out that Patient X doesn't do mammograms or statins and then being expelled to blot the escutcheon of some other hapless M.D. That's what happens when you do cookbook medicine and the book in question becomes more important than the patient.

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