Response to Dr. Pauline Chen's essay on "Getting Off the Patient Treadmill"

Dr. Pauline Chen’s concerns about health insurers paying physicians by comparing them to standards of cost-efficiency are timely and necessary. (Feb. 19, 2009, Link)

The biggest worry is that these pay for-performance [P4P] programs are driven mostly by a desire to cut costs, which in itself is not a bad thing. But since cost-cutting permits insurers to increase profits and dividends to their shareholders, doctors’ needs (and patients’) are obviously jeopardized. These programs are intended not only to cut costs but to control the way that physicians practice.

Although the standards that define the P4P plans have some value in treating patients, in real life, the many nuances of patients’ personalities and socioeconomic backgrounds make it impossible to grade accurately and fairly the comprehensive worth and competence, the total professionalism of any doctor. Attempting to do so robs doctors and patients of their unique qualities and all the nuances that enter into doctor-patient relationship, reducing both to faceless rows of data in statistical charts, which is the way that insurers deal with them.

But beside P4P strategies there are other that insurers use to control doctors. For instance, recently I received a brochure from UnitedHealth (1) informing me that I did not meet their “physician designation program quality and cost efficiency assessment” because I was no longer board certified in family medicine. Physicians are given two designations by UnitedHealth: one star for quality and two stars if both quality and cost effective standards are met. The information is then displayed in online directories for pubic viewing. They allow physicians a 45 day review period to clarify and request reconsideration of their designation status.

I considered writing a letter to them explaining why I thought they were unjustified and simply wrong in profiling me according to their standards. After all, they don’t know my patients or their personal needs, the socioeconomic climate of my community and the number and types of specialists in it. They don’t know how much time I spend with my patients or how well I connect with them or how successful I am in forming therapeutic relationships with them. Neither do they know how timely I am in making referrals or how hard I try to give patients same day appointments or how attentive I may be to their emotional needs. They know nothing of my character or integrity. They have never visited my office and don’t even know what I look like.

Also they don’t know that I had been board certified for over 30 years and that the boards no longer reflect how my general practice has tailored itself during that time so that it no longer represents the “generic” models the boards zealously want to impose regardless of physicians’ individual differences.

Although UnitedHealth states in their brochure that their physician designation program is not intended as a guarantee of a physician’s competence, clearly their profiling carries with it an implication of quality and competence that could prove harmful to any physician’s reputation and livelihood whose name is not included.

Insurance companies have no role in profiling physicians under any conditions. Profiling coerces doctors into following insurers’ policies and gives insurers a license to determine how medicine is practiced. By compartmentalizing doctors according to set standards that only reflect the cost-cutting and “scientific” side of medicine insurers make it impossible to concentrate on the non-scientific or humanistic side of medicine. And for the extraordinary doctor who does take the extra time to talk with patients and discuss their concerns and form a trusting and personal relationship, no set of pay –for-performance standards exist; and for many other other statistically independent functions which insurers do not acknowledge. In this context both patients and doctors become dehumanized, faceless cogs in the health care machine.

I decided not to appeal UnitedHealth’s after I read that UnitedHealth was sued for fraudulent billing practices (2) that exploited patients and physicians alike.

Seeking approval from an organization that used fraudulent business practices against doctors was senseless. It would only make me a hypocrite. Worse it would imply that I agreed with UnitedHealth’s flawed policy of quality and cost-effectiveness profiling.

Clearly, P4P programs and any other physician designation programs are an insult to doctors and just another example of how bad it can get for doctors when insurers impose standards for quality and cost-effectiveness. Hospitals have peer review committees that monitor physicians’ work and doctors themselves are committed to life-long study to improve their skills. Many mistakes in medicine are made because of poor judgment, fatigue, overwork, or communication and system failures—ironically some of these some of these factors are due to the working conditions imposed by health insurers--not lack of knowledge.

Pay for performance may make sense when it comes to making inanimate objects like automobiles, computers and radios.

But it’s bad for doctors and bad for patients.

1. UnitedHealth Premium Designation Program. Brochure. United HealthCare Services, Inc. Oct. 2008.

2. Nielsen NH. United agreement a victory for fair pay for physicians. Amednews, www.ama-assn.org/amednews/2009/02/09

Ed Volpintesta MD