P4P: Two studies raise issues re: discrimination, disparity in care

Pay-for-performance (P4P), also called value-based purchasing, is a payment model that government and private payers alike are turning to as they seek to obtain higher-quality, lower-cost healthcare services from providers. However, two recent studies suggest that P4P may have some unintended consequences that could deep-six some of its good intentions.

P4P measures often are strictly outcomes-based and don't account for patient-related complications, most commonly obesity, that could impact those outcomes, according to researchers from Johns Hopkins University School of Medicine in Baltimore, Md., presenting at Digestive Disease Week 2010 in New Orleans, reports MedPage Today. Consequently, physicians may face unintended financial incentives to discriminate against obese patients.

In a national review of insurance claims for 36,483 patients who had had one of two common general surgical procedures, obese patients undergoing an appendectomy had a 25 percent higher risk of experiencing complications (e.g., re-operation, infection, hemorrhage) than non-obese patients, and patients having a cholecystetomy were 7 percent more likely to have complications (e.g., blood clots, re-operation, infection), found senior author Dr. Martin Makary, M.PH., surgeon and associate professor of public health. In addition, obese patients' care cost more. The median total inpatient costs for obese patients were $2,978 higher for cholecystetomy and $1,600 higher for appendectomy.

With obesity rates highest in minority populations, P4P could raise potential discrimination issues. "What sounds good in theory turns out in reality to punish doctors who take care of more high-risk patients, and actually financially incentivizes discrimination," said Dr. Makary. Standardized outcomes accounting for patient factors, like those used in the American College of Surgeons' National Surgical Quality Improvement Program, would level the playing field and knock out discriminatory incentives, he suggested.

Similarly, a RAND Corp., study published in the May issue of Health Affairs found that, with the existing gaps in healthcare quality for vulnerable populations, most physician practices serving those populations would receive lower payments under a P4P model than other practices. In a simulated P4P program in Massachusetts, a typical physician practice serving higher proportions of the most vulnerable patients would receive about $7,100 less per year. Such lower payments in turn could result in medically needy communities losing resources.

"Paying for performance may have the unintended effect of diverting medical resources away from the communities that need these resources the most," said Dr. Mark Friedberg, the study's lead author and an associate natural scientist at RAND. "If you don't watch where the money goes, pay-for-performance programs have the potential to make disparities worse."

To learn more:
- read the MedPage Today article
- read the Digestive Disease Week abstract
- read the RAND press release
- read the Health Affairs abstract

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