Saturday, December 25, 2004

Pay-for-performance is coming to town

Santa took a break at our house last night. Midwestern snowstorms had put strain on his reindeer. They napped on our forested lot, while Santa and I had a fireside chat. I wanted to know what people were asking for this year.

"Lots of requests about healthcare," he said, eyeing a plateful of cookies. "People asked me for harmless meds. All benefits, no risks. Had to disappoint a lot of folks. And requests for cheaper meds, better cures, the usual.

"But the biggest surprise? There were requests - more like demands, really - for doctors and hospitals to show that they are competent, and use proven treatments, or face consequences. Ho-ho-ho! Let's have some more eggnog."

Doctors proving their competence, or facing consequences? But, Santa...there are so many variables among patients, and so many different opinions about what should be done. The standard of care is so broad - it ranges from the most superior care you can give, to the average, reasonably expected care. How can our performance be measured and compared?

"Mark my words. The time will come when even psychiatrists will have to show that patients with 'a, b, and c' symptoms are getting 'x, y, and z' treatments. Just look at what they're doing already, with other specialties. Look at pneumonia vaccines."

What pneumonia vaccines?

"Hospitals are pulling out bells and whistles for acutely ill pneumonia patients, but they send vulnerable patients home without the vaccine. When word leaked out, it became a scandal. Now they'll be holding feet to the fire if the vaccine isn't given. It's in today's New York Times.

"Vaccines are just the beginning. Pay-for-performance is on its way, for doctors and hospitals. They're making a list, checking it twice." He downed his second cup of eggnog.

But Santa...why are hospitals taking the rap? Vaccines are part of good outpatient care. And what about patients who refuse to see their PCP's for preventive care, or who refuse the vaccines? Shouldn't patients share some accountability? And how do we know that those patients are giving informed consent for their vaccines?

"Ho-ho-ho! You'll have to ask Medpundit that one...let's see, she's next on my list... but the juggernaut is rolling, take it from me. Doctors will have to be very publicly accountable for specific things. Ho-ho!"

He climbed back into his jolly sleigh and flew away. Is he right? Will my "performance" be measured and rated, according to clinical guidelines? Santa seems to know what he's talking about. I'd better get my list ready for next year. I'll be asking for some wisdom, to figure out what's being asked of me in coming years.

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