P4P: Wolf in Sheep's Clothing?

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P4P: Wolf in Sheep's Clothing? => Spring 2006

John Burigo, M.D.

Pay for performance is the new buzzword in insurance circles. A promise to enhance physician revenue if certain performance measures are documented. The Blues have already rolled out their program called Recognizing Physician Excellence or "RPE." Currently, their performance bonus is paid out annually and is in addition to standard reimbursement rates. Performance measures include rates for completing recommended screening protocols for pap smears and mammograms, certain CME courses, patient satisfaction surveys, and participation in an e-medicine program that they promote to facilitate communication and treatment of patients via e-mail.

Medicare just instituted PVRP (Physician Voluntary Reporting Program). Beginning January 1, 2006 we are being asked to voluntarily submit a "G-code" with our bills to "help capture data about the quality of care provided to Medicare beneficiaries." G-codes have been established for several measures such as:

G8051:	Elderly female documented to have been assessed for osteoporosis
G8060:	Patient documented for assessment of urinary incontinence
G8111:	Patient documented to have a mammogram in the past year

There are 36-G codes this year, each with its own related code indicating that the patient has not had the service. It is interesting that there is no code for the common scenario: patient recommended to have
XYZ service but failed to do so. There is also no compensation for these G-codes.

I can't help but be reminded of a time in the late '80s when we were approached by the insurance industry to participate in a voluntary program called the PPO. We were promised an increased number of patients and rapid reimbursement to sit on a "select" panel of providers that would accept a small decrease in reimbursement. That system has developed into a quagmire of authorization, verification, 60-day filing limits, withholds, recoups, capitation and reduction in fees that far exceed the initial 10% agreed to.

I caution everyone to carefully evaluate your participation in any of these programs. They could be the first step that leads down the path to a system where you will be paid less for what you do, only to have a chance to recoup the difference by "performing" according to criteria established by whom? The insurance industry or federal agencies? It will not be good enough to practice good medicine, you will be responsible for proving that you do so, and patient compliance will now be a component of your quality of care.

P4P—the concept is good as long as it rewards quality in medicine over and above a reimbursement system that has hit rock bottom. Can we trust payors to do that? I wish I had the answer. We should be cautious.