Pay for Performance (P4P) and total error


P4P has been around for a number of years as a way to reward and punish physicians financially based on selected measures. P4P has been widely criticized, here for example and also in the NEJM.

I disagree with one P4P criticism that the work of a physician is so complex that judging performance is impossible – it would be easier to split the atom. The problem is rather that a subset of performance measures has been chosen and without the entire set of performance measures, the result is similar to my last post although in this case it is like having a dictionary with only the letter “C.”

An alternative would be to use a total error concept. That is, for any patient care episode, what errors have been made? Errors could not only include harm but could be financial as well. Thus, if a physician ordered unnecessary blood tests, financial waste has occurred. The value of total error is that there is no modeling – all errors would be captured by examining whether there is harm (or waste) in the care of a patient. Thus, there is no list of performance measures. And yes, there can be a physician error even when the patient presents with a complex set of symptoms. But the concept is impractical because one would need a panel of experts – see for example a NEJM case study – for each patient encounter.

Another approach would be to evaluate known cases of patient harm in a NTSB type of approach. Here the goal would be to understand causes to reduce error rates. In certain cases such as incompetence, physicians would be punished but in other cases, process improvements including better training might would be used.


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