Bridges to Excellence CEO responds to P4P and ethics

De Brantes says P4P is a 'misnomer'

Bridges to Excellence (BTE) CEO Francois de Brantes doesn't mince words when asked if he thinks there is an ethical conflict between the payment model of pay-for-performance — essentially giving physicians additional payments for good performance based on certain quality measures — and ethical decision-making by physicians.

de Brantes heads a not-for-profit organization, started in 2002, that utilizes the pay-for-performance model. Its members include physicians, health plans, quality experts, consultants and large U.S. employers, with its charter members including General Electric, IBM, UPS and Procter & Gamble. The BTE literature suggests that by meeting performance measures, its physicians "could see income gains of up to 10% in the form of annual bonuses paid by participating employers and health plans."

"First of all, just from my perspective and context, I really dislike the term 'pay-for-performance,'" de Brantes tells Medical Ethics Advisor. "And the reason why I dislike the term pay-for-performance is that it's actually a misnomer. Payment is always for performance. The question is: performance of what?"

In today's health care payment environment, he says, about 80% of payment is for transactions, which means that physicians are incented to complete more transactions, i.e., their "performance is based on the volume of transactions that [they] bill."

With capitated fees, which comprises the remaining 20% of physician visits, the incentive with the capitation model is to remain within a set budget, or, de Brantes says, "the performance that's motivated is lack of volume, or fixed volume."

"Fee-for-service motivates lots of volume, or I think, there is irrefutable evidence that there's massive amounts of excess volume, which is being delivered in the country. Is that good for patients?" he asks. "I mean, that's an ethical question, right? . . . no one, unfortunately, bothers asking the question, but does fee-for-service inherently encourage providers — physicians and other clinicians — to do things that would otherwise go against their professional behavior?"

de Brantes contends that there are numerous examples — from over-prescribing antibiotics just because a patient asks for one — to infections that occur in hospitals when they shouldn't that result in additional costs for insurance companies.

In other words, de Brantes contends that none of the existing payment models are ethical, because behavior is always being incented toward a desired end.

"I think it's a fool's dream to think otherwise," de Brantes says. "So, once you [view] that as the context, now you have to think about, ultimately, how do you craft payment incentives that are going to — more optimally — reward the right type of behavior?"

To correct what he thinks is the misnomer of pay-for-performance, de Brantes, instead, focuses on what he calls "payment for results."

de Brantes suggests that rewards for results are not the same as rewards for financial results. Instead, payment for results emphasizes "measurable results of the effect of all these services that have been delivered by the clinician to the patient."

"So, at that point, the question becomes, is that better or worse than what we have today? And how is it different, and what kind of behaviors might it encourage? And is there a way to mitigate for those negative behaviors?" he asks.

de Brantes says one of the typical arguments from physicians who are considering entering into pay-for-performance models is that, by being held to evidence-based medicine, he or she will not be able to deliver care that addresses each patients unique needs, because his or her professional judgment is now held hostage to what evidence-based medicine would indicate for care. But being guided by evidence vs. "guesswork" in the delivery of care is a good idea.

de Brantes does agree with the critics of pay-for-performance that when physicians' results are measured for a particular condition as a group, those patients with multiple conditions may affect the results for a particular condition.

But his answer is simple: "You don't count certain patients. You exclude them from the measurement scheme."

That's because, unlike what many physicians assume, the pay-for-performance model doesn't measure in absolutes, he says.

"What you're looking for is — are the majority of patients being controlled adequately," he says.

Another common argument that he says physicians present against pay-for-performance, that because they will be judged based on their patients' outcomes, they may be encouraged to stop seeing non-compliant patients who are less likely to do well.

Again, de Brantes says, "no one" that he knows who endorses pay-for-performance judges physicians by their measures of outcomes in absolutes.

He also suggests there are more allowances being considered for socioeconomic factors in recognition that some patients from various socioeconomic backgrounds are going to have more difficulty complying with their doctor's directives.

de Brantes suggests that in those instances, if a physician is having difficulty communicating with a patient, the patient may be better served by going to a different physician.

The unethical behavior, in such an instance, occurs when a physician will not admit that he or she is having difficulty with a patient and continues treating that patient with, perhaps, poor results.

"The ethical thing is to look squarely in the face of the facts and understand and recognize that there are some patients in the practice with whom you're having a tough time," he says. "That's the ethical conduct."

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