It is undoubtedly true that some physicians use any available excuse to avoid changing their practice, including the changes promoted by the proponents of evidence-based medicine and related P4P. That fact does not negate the reality that there are serious and legitimate objections to EBM and P4p in their current states of development.

First there are serious questions about the quality of the evidence. Practice guidelines like the ADA diabetes guidelines are complex and nuanced, but when translated to NCQA criteria and P4p measures the nuance is gone. The translation of research evidence into practice usually yields less favorable results than predicted by the research findings. For example, one recent study found that most of the recommendations of the American Heart Association Guidelines for CHF were not associated with any difference in outcomes in clinical practice.

Most of my patients (average age 80) have multiple diseases, not one. What guideline prescribes the optimal care for a patient with CHF, diabetes, arthrits, osteoporosis and depression. I would argue that the optimal care for the patient with 5 diseases is not the sum of the optimal care for each of the diseases. If you treat the patient according to all 5 guidelines, she will be on 15 or 20 drugs, be instructed to make humanly impossible lifestyle changes,will be unable to execute the treatment, will be unable to afford the treatment, and frankly, will not survive the treatment!

No guideline will specify the optimal care for the enormous number of combinations of disease, socio-economic status, insurance restrictions, and patient preferences.

Of course, one can use guidelines in a prescriptive manner for the care of the simple patients, but they are not the ones that cost the money.

EBM and P4P are seductive concepts, but putting them into practice in the real world is fraught with difficulties.

The current payment system is broken. When I sat on a non-profit hospital board, I listened to the discussions about which services are profitable (cardiology and ortho especially). The hospital business plan was to pump up the volume of these services, and close others, like psychiatry, that were impossible to make money on. All the hospitals have the same winners and losers. (This also accounts largely for the specialty hospital phenomenon). The reason is that the administered prices are wrong. Some things are overpaid, some underpaid, systematically. When CMS tired to correct this last year, they caved in to enormous pressure from the hospital lobby. They like it just the way it is, thank you. Physicians aren’t the only ones for whom self-interest is a motivator.

The same sytematic payment disparities characterize physician payment, favoring procedures and disadvantaging cognitive work. As a result, primary care is in desparate straits. I predict a war within the medical profession over this issue.

Why should we waste policy energy on tinkering with a limited model like gainsharin, wasting political capital on fixing a problem which won’t solve the real problem — the one that really needs attention — a new sustainable payment model that encourages quality with resourceful expenditures that lower waste and improve underuse?

When we present PROMETHEUS Payment to provider groups — hospitals and physicians — they immediately grasp it’s appeal but observe “oh this will be really complex.” Of course it will. If it were simple it would have happened thirty years ago. In fact, the actual implementation of the program by providers is not unmanageably complex and draws on practices that should be in place anyway. The real complexity lies in the development of the software package that permits tracking of data and allocation of dollars in accordance with the incentives and the scorecard. And that is already being created before the program even hits the sidewalk, so when we go live it will be real. Let’s just pull up our socks and get on with the hard work already and stop looking for quick fixes.

Alice Gosfield
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But, the fundamental problems in many of the payment reform models recently discussed include the following: (1) the parties subject to the incentives have to form new legal structures (e.g., PHOs, IPAs) to play; or (2) someone holds the money of someone else for distribution; or (3) someone wants to or has to give a piece of their money to someone else (e.g., gainsharing); or (4) there is a single model through which the parties are permitted to act if they are to take advantage of new incentives. How can this constellation of characteristics possibly advance quality over the long term?

The principal goal should be to pay fairly for the right bundle of services patients need for their clinical conditions, with incentives that lower administrative burden, enhance quality, and foster clinical collaboration. The PROMETHEUS Payment model — two years in the making (www.prometheuspayment.org), does that by basing case rates on the resources necessary to provide all the care that good guidelines say the patient should receive, adjusted upward for co-morbid conditions requiring more time, effort and resources, measured in a scorecard. One of the cardinal principles of this model is that no one holds the money for anyone else unless they choose that configuration, yet all share the same clinical incentives. This happens in two ways: (1) Each provider, group of providers or combination of providers, on one hand, and the plan, on the other, agree on the scope of services the provider will provide and at what price. A portion of that price (10% for chronic care and 20% for acute care), is held back in a Performance Contingency Fund which is paid to the contracted provider, pro rata, in accordance with the calculated scores above a quality baseline. (2) The scores turn 70% on what the measured provider does and 30% on what all the other providers treating the patient on that Evidence-informed Case Rate do.

The beauty of it, among other things, is that not only are there virtually no fraud and abuse implications were it to be employed in Medicare, but because of the elimination of time-wasting administrative burdens (e.g., prior authorizations, certificates of medical necessity, concurrent review, post-payment audits, and more), more time can be spent with patients; and providers can improve their financial margins and efficiencies. The most recent iteration of its principles, (http://www.gosfield.com/PDF/PrometheusPayment2.pdf) sets forth the contracting and legal context which will make the program real. PROMETHEUS Payment Inc, is currently identifying pilot markets to test the concepts in real world settings and expects to go live in the second half of 2007.

Why should anyone care now if the new model is not yet coming to a theater near you? Especially with regard to hospitals and physicians, the forms of clinical collaboration which the PROMETHEUS Payment model rewards are what they can and should be doing anyway. Finding a solution to the lack of care coordination and appropriate common incentives across the care continuum should not be driven by the apparent convenience of a unitary structure or mode. Instead it should be guided by sound principles and policies around which robust and flexible solutions can emerge. Clearly, hospitals cannot survive without the passionate engagement of their physicians with them, particularly around quality. This engagement, however, need not depend on a formalistic extended medical staff structure, but rather on a recognition that what matters – such as how patients are treated before they get to the hospital, their condition when they get to the hospital, the optimal moment for referral from primary physician to specialist and beyond, as well as what happens in the hospital and after discharge — are all quality and business case-relevant to all parties. The PROMETHEUS Payment model offers Provider payment Reform for Outcomes, Margins, Evidence, Transparency, Hassle-reduction, Excellence, Understandability, and Sustainability without the need for new legal configurations and financial risk among providers. Let’s not repeat the mistakes of the past that have taught us that any solution built around a specific vehicle for care delivery and payment will only lead to stifled innovation, burdensome bureaucratic oversight, and, ultimately, anger, resentment, and failure.

Alice G. Gosfield, Esq.
Chairman, PROMETHEUS Payment Inc.
http://www.gosfield.com/www.uft-a.com