A Pay Cut by Any Other Name Is Still a Pay Cut

Dear Editor:

I would like to commend Robert H. Miller, MD, on a well-balanced discussion in the February issue of ENToday concerning the pros and cons of pay for performance (P4P).1 I would like to add a few comments and predictions about P4P that are not so well balanced.

P4P promotes itself as a means for improving quality of care. I reject this notion. Good physicians who recognize that a patient should not follow the P4P paradigm will be punished with lowered reimbursement. On balance, the P4P format will be a drag on innovation since this too will be punished. However, unscrupulous physicians will fill out the paperwork and doctor the chart in order to get their bonus regardless of what they actually do.

Dr. Miller rightfully points out that the financial incentives must be material. The proposal of a 1.5% bonus from Medicare is definitely not material. Consider the alternatives:

1. Treat 200 Medicare patients. Follow the cookbook routine of their recommendations, fill in all the paperwork, and then wait for your 1.5% bonus. However, if you forget to dot an i or cross a t, the bonus doesn’t come. Worse, you could be liable for a penalty or even accusations of fraud.

2. See the 200 Medicare patients as above and then see an additional three patients. Forget about all the paperwork, cookbook medicine, fear of penalties, etc. The end result is an assured 1.5% bonus. An added benefit is actually practicing medicine the way you want-not how the government decides.

Most physicians who have thought about this have probably already figured out that option number 2 is easier, professionally more satisfying, and a sure thing with regard to the 1.5% bonus. Those who haven’t figured this out yet will probably figure it out after they have been through the process a few times and have not seen significant remuneration for their efforts.

Now, I don’t feel that I am a genius for having figured this out. I strongly suspect that the Center for Medicare and Medicaid Services (CMS) understood this as they put the plan together. To CMS, this is an easy way for physicians to accept a 1.5% pay cut voluntarily-of course, under the guise of improving quality of care. A pay cut by any other name is still a pay cut.

My prediction for the future: Less than 10% conformity with P4P and the only improvement in quality of care will be found in Medicare paperwork. Physicians who comply and those who don’t will have the same results-working harder and faster to make the same (or less) money. The perverse part of this is that physicians who comply with P4P open themselves up to more scrutiny and a greater chance for an audit-all for a nonmaterial financial incentive.