Pay-for-performance could end up penalizing doctors who care for the sickest patients—the elderly.
For the many groups devising pay-for-performance guidelines, the elderly pose a special challenge. They tend to be sicker and costlier to treat than younger people, and their care accounts for the lion’s share of medical expenditures. Yet few P4P measures have been developed with older patients in mind.
Performance measurements for diabetes, for example, are based on study data from patients younger than 75—but more than a third of diabetes patients in Medicare are 75 or older, says Caroline Blaum, associate professor of geriatrics at the University of Michigan and a research scientist with the Veterans Administration Geriatric Research, Education, and Clinical Center in Ann Arbor. “We have no idea what would happen if we conducted the same studies on 80-year-olds,” Blaum says.
Another hurdle is that most P4P research focuses on individual diseases, whereas older patients tend to have multiple chronic conditions. In a Johns Hopkins University study published last year in the Journal of the American Medical Association, researchers considered the hypothetical case of a 79-year-old woman with chronic obstructive pulmonary disease, type 2 diabetes, osteoporosis, hypertension and osteoarthritis. While there are P4P practice guidelines for each illness, a doctor who followed all of them for this hypothetical patient—to provide “good” care, according to P4P standards—would have prescribed 12 medications requiring 19 daily doses, at a monthly cost of more than $400. In such a case, a physician who considered the patient’s overall condition would likely manage her care differently, perhaps resulting in a better medical outcome but poorer scores for the doctor on the single-disease P4P measures. The study noted that doctors treating elderly patients in P4P programs may be forced to choose between good care and financial rewards.
One solution to this generation gap would be to exclude older patients from a doctor’s practice for P4P purposes—for example, by applying a particular standard for a disease only to patients 75 or younger. Such “risk adjustment” would prevent doctors from being penalized for treating elderly patients with multiple conditions. But it would take large numbers of patients out of the P4P equation and remove incentives to improve care. “We need to find a way to reinforce quality while avoiding unintended consequences for doctors and patients,” Blaum says.