Pay for Performance: Behind Closed Doors

We need to sit downand have a seriousdiscussion aboutthis pay for performance(P4P) conceptbefore it gets further out of hand.Insurance companies are telling doctorshow to practice medicine—doesanyone see the folly in that approach?We simply must have a heart-to-hearttalk with those insurance companies. Ifigured I'd start with Pinnacle InsuranceGroup Services (PIGS), a dominantinsurer with a 98% market sharein most of the country. I made an appointmentwith their CEO, a man bythe name of Mr. Rich Goldfinger.

Dr. Constan: Mr. Goldfinger, I'mconcerned about your new policy ofwithholding reimbursements until doctorsimprove their Health Plan EmployerData and Information Set (HEDIS)scores. Do you think we're not alreadytrying to do the best job we possiblycan with our patients? When patientsdon't get recommended care, it's usuallybecause they don't get their lab tests,take their suggested medications, orshow up in the office for their appointments.If you make us financiallyliable for the poor health behaviorsand decisions of our patients, you'llsend us to the poorhouse.

Mr. Goldfinger: Your thinking is allwrong here. We're a business, and wehave to compete with other businessesfor the premium dollar; therefore, wemust give good services to the employerswho pay us. I've managed to decreaseour payouts last year by 2.5%.That's remarkable, don't you think,what with inflation and all?

Dr. Constan: I'm interested in whenyou say you're a business—what exactlydo you mean by that? Do you seeyourself in the health care business?

Mr. Goldfinger: We collect premiumsand do payouts, and in between,we attempt to maximize our profits.The fact that our payouts are to doctorsand hospitals isn't really part ofthe equation as we see it.

Dr. Constan: But can you admit thatyou are still trying to change health carebehavior by "rewarding" certain behaviorsby doctors??

Mr. Goldfinger: It is mostly a promotionaldeal to sell ourselves toemployers, who want to see value fortheir dollar. It's your job to provide theactual health care.

Dr. Constan: How much money didyou make last year?

Mr. Goldfinger: $147 million, includingbonuses. I deserved my salarybecause the work I do increases thecompany's profits.

Dr. Constan: And you believe thatdoctors should be more like you, andattempt to always maximize their profits—that's why you believe so stronglyin P4P, isn't it?

Mr. Goldfinger: Of course, we livein a capitalistic society. That's how thesystem works.

Dr. Constan: Okay, then let me ask:If you were very sick and went to seeyour doctor, would you want to knowthat your doctor was intent on maximizinghis income by increasing hisHEDIS scores, or that his primary concernwas seeing you get well?

Mr. Goldfinger: I'll allow him towork on his HEDIS scores, but I wouldalso want his maximum effort to helpme as a customer.

Dr. Constan: But maybe you won'tbe able to have both. If you get yourway and everything revolves aroundthe almighty dollar, you just mighthave to live with the P4P system youset up—and its consequences. By theway, have you ever considered thatP4P could apply to your performanceas well? In other words, you yourselfcould get graded on how you run yourcompany, based on certain measures ofquality. I daresay most people wouldconsider that a good insurance companyis one that pays a maximum amountof money for actual health care, and aminimum amount towards administration.They would also like to know thatyour doctors are reasonably happy withyour service. I don't think your highsalary would look too good underthose conditions.

Mr. Goldfinger: If you can convincemy board of directors of that, you'rewelcome to try.

Dr. Constan: One final question.How much of your gold would youspend to get a doctor to go out on alimb for you—to get you the medicalcare you needed but that your insurancecompany would not pay for?

Mr. Goldfinger: ?

Louis L. Constan, a family practice physicianin Saginaw, Mich, is the editor of theSaginaw County Medical Society Bulletinand Michigan Family Practice. He welcomesquestions or comments at 3350 ShattuckRoad, Saginaw, MI 48603, 989-792-1899, or louisconstan@hotmail.com.