Pay-for-performance draws doctors' ire

Las Vegas -- Physicians attending the AMA's Interim Meeting vented their doubts, frustrations and concerns about pay-for-performance. But when the Association's meeting wrapped up, they decided not to make a policy change.

The issue was in the air from the start. During the opening session, AMA President William G. Plested III, MD, expressed his views to the Association's House of Delegates in an impassioned speech.

"Most of you know what I think of this whole idea, so I won't dwell on that," he said. "I will point out that -- reminiscent of the managed care debacle -- P4P will allow insurers to dictate the treatment that we give our patients and will publicly label any physician foolish enough to contract with them and not follow their dictates as nonpreferred, substandard or some such label."

Dr. Plested said AMA guidelines can be used to identify which programs are quality-based, fair and ethical. But he said he did not know of a pay-for-performance program that had been subjected to a thorough review and was found to be in compliance with all of the guidelines.

AMA policy says pay-for-performance programs must ensure quality of care, foster the patient-physician relationship, offer voluntary physician participation, use accurate data and fair reporting, and provide fair and equitable program incentives.

Health and Human Services Secretary Michael Leavitt, the keynote speaker at the AMA's opening session, told physicians there is still a lot to learn about measuring quality.

"When we talk about building this system, people envision the equivalent of a race car that travels at 238 mph around a track," Leavitt said. "The reality is we have a little pile of wheels, a small frame, a lawnmower engine and makeshift steering wheel. We're assembling a go-cart just to demonstrate that we can make it work. Once we have, we'll build it into a race car. We have to start at a very rudimentary place and grow into it."

Hot topic of debate

Leavitt said his travels had shown him that there is tension between physicians looking to improve quality and large employers, unions and health insurance plans that want to lower health care costs. It's a difference between measuring quality perfectly and measuring quality quickly, he said.

"If the MDs don't develop quality measures, the MBAs will," Leavitt said. "It will be a lot better if the MDs do it than the MBAs. We need your continued involvement in this subject. The AMA has been heroic in their willingness to engage the specialty societies and to work to develop quality measures. Please keep it up."

Leavitt recognized the need for quality measures to be done locally.

"I don't believe now, or in the future, that physicians will trust a quality measurement system made in Washington," Leavitt said, drawing applause from physicians.

During delegates' committee discussion on legislative issues at the meeting, two resolutions on pay-for-performance were hotly debated. One proposal wanted the AMA to strongly oppose pay-for-performance, launch a campaign to discredit it and label it as economic credentialing.

The other resolution called for the AMA to oppose any congressional action that would require a pay-for-performance program as a part of physician payment from the Centers for Medicare & Medicaid Services.

Many delegates used the opportunity to voice their displeasure with pay-for-performance.

"It's inevitable that this is going to cause physicians to drop out of plans," said Peter Lavine, MD, an alternate delegate and orthopedic surgeon in Washington, D.C. "This is going to be an onerous process.

"Pay-for-performance is going to be a bigger nightmare" than the sustainable growth rate, he added.

Alternate delegate Billie Jackson, MD, a dermatologist in Georgia, said: "My fear is pay-for-performance is leaving the station. Pay-for-performance is taking us to a place none of us wants to go."

Other delegates said pay-for-performance is here to stay and that physicians should accept it. But in the end, neither resolution was adopted.

Delegates said the resolutions should be considered together, and they referred both to the AMA Board of Trustees for a report back to the house at the 2007 Annual Meeting.