Should Doctors be Paid More for Better Results?

The idea seems straightforward and logical: doctors, medical groups, and hospitals who achieve better clinical results for their patients should be rewarded — financially. This “pay for performance” idea (P4P) intuitively jibes with other aspects of capitalist society. After all, there’s a reason why Lebron James is paid more than Lauri Markkanen.

Such a system in theory should keep the stars happy and motivate everyone else to try harder. Past attempts to institute the theory into American medical practice, however, led to mostly disappointing results, with many unintended consequences. For example, one Medicare pay-for-performance program (https://www.acpjournals.org/doi/10.7326/M17-1740) exacerbated societal inequities by indirectly penalizing doctors caring for the poorest and sickest patients, while overall quality and costs scores did not improve (Ann of Int Medicine 2018;168:255). Thus, P4P plans which emphasize outcomes incentivize providers to avoid caring for (poorer, sicker) patients who are less likely to achieve the desired results.

On the other hand, many healthcare providers have argued that P4P plans which emphasize “best practices” may incentivize them to practice “in order to check the desired boxes” instead of achieving the best results. Skeptics suspect that P4P programs are more about trying to reduce overall payments to providers than actually reward superior performance. And, with administrative costs now consuming over one-third of every health care dollar (https://www.healio.com/primary-care/practicemanagement/news/online/%7B83beb11a-add5-4324-9bef-03f5edc21f88%7D/a-third-of-us-health-care-spending-stems-from-administrative-costs), no one is particularly thrilled about doing more paperwork (even if all the forms are computerized).

But the P4P idea persists, with proponents arguing that we just have to find the right balance of process vs. outcome measures to achieve the goals of optimal results. And there have been some successes. A Taiwanese study published in 2020 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7035087/) demonstrated improvements in the average complication and death rates in 5478 diabetic patients enrolled in a P4P program compared to 5478 patients in traditional fee for service over an average 4.3-year follow-up period. A total of 250 patients died in the P4P group compared to 395 in the control group. Ophthalmology has its own national P4P program, the Merit-Based Incentive Payment System (MIPS). Practices decide which aspects of care (outcome measures) most applicable to its patient population, with six measures required to qualify for the Quality Performance Category.

Examples of such quality measures include:

1. Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) who have an optic nerve head evaluation during one or more office visits within 12 months.

2. Percentage of patients 18-75 years of age with diabetes and an active diagnosis of retinopathy overlapping the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period.

3. Percentage of cataract surgeries for patients aged 18 years and older with a diagnosis of uncomplicated cataract and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved in the operative eye within 90 days following the cataract surgery.

4. The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as tobacco use.

Another aspect of MIPS is an effort to promote “interoperability” – which basically means electronic health records which talk to outside systems. Examples include e-prescribing, patient electronic access to their health information, and syndromic surveillance reporting. MIPS has been active in ophthalmology for about three years now.

Ticho Eye Associates is pleased to report that we have met the quality requirements. The program certainly has increased electronic “paperwork”; nonetheless, the efforts have succeeded in changing our practice pattern, in that the doctors and staff members are tuned into meeting MIPS requirements.

It remains to be seen if all the fuss is worth the bother….

Benjamin H. Ticho, MD