Pay-for-performance programs can cause gaps in quality of coverage for obese, minority patients

Worsened care for minorities, as well as the obese and poorer people, could be an unintended consequence of physician pay-for-performance (P4P) systems unless they're adjusted to account for case complexity, two recent studies have concluded.

Johns Hopkins researcher Martin Makary, MD, found that physicians have more incentive to "pass on, stall or delay treatment" to obese such patients in need of gallbladder or appendix surgeries because they're statistically more likely to experience complications than their non-obese counterparts. 

This also puts African-Americans at risk, since they're known to experience higher obesity rates than whites. Makary's conclusions were based on 35,000 insurance claims for patients who underwent gallbladder removal and more than 6,800 patients who had appendectomies between 2002 to 2008.

"[Rewarding providers based on outcomes] can be discriminatory and create perverse incentives when metrics aren't adjusted [for case complexity or co-morbidities]," said Makary, who presented his findings this week at Digestive Disease Week, the largest gastrointestinal medical conference in the U.S. Obesity is "hands down" the most common co-morbidity that skews outcome, he said.

A RAND Corporation study that came to a similar conclusion simulated the impact of a P4P program on primary-care doctors in Massachusetts. A typical physician practice serving the highest proportion of medically vulnerable patients--i.e., low-income minorities--would receive about $7,000 less each year using a P4P model. 

"We found that practices that treat vulnerable populations have room for performance improvement, so it's important to preserve the incentive to improve quality of care while taking steps to prevent an increase in disparities," said Dr. Mark Friedberg, the study's lead author. His study appears in the May issue of the journal Health Affairs.

Instead of simply trying to increase the number of primary-care physicians in the U.S., community-based primary care providers should be financially supported more than high-technology services, he writes. Improved communication between specialists and primary-care doctors also could help with such a reorientation process. 

For more information:
- read this EmaxHealth piece
- check out this article on Science Centric
- read this RAND Corporation press release
- here's an abstract of Friedberg's study in Health Affairs
- here's a second abstract of an empirical review by Friedberg, published in Health Affairs