The American College of Cardiology and the American College of Physicians have signed on to “pay for performance” whether we like it or not.
To prevent the scheduled 5% cut in physicians' fees under Medicare, our representatives agreed to a program that will pay physicians who volunteer to participate, an opportunity to win quality points to receive an additional 1.5% annually.
It is worth noting that the ACC and the ACP were 2 of only 4 out of 21 medical groups that supported the legislation. Notably, the American Medical Association chose to decline, having resisted this deal in part because of its reluctance to accept the concept of pay for performance.
Pay for performance will reward those physicians who adhere to quality standards, whatever they may be, and penalize those who do not. Most observers feel that this has nothing to do with quality and everything to do with the cost of care. Many are skeptical that it will achieve either objective.
The idea that doctors must be financially rewarded to provide quality medical care should be abhorrent to any practitioner. It suggests that doctors know what is best for the patient but will not provide that care unless they get a few more dollars in their pockets.
The Centers for Medicare and Medicaid Services and the Institute of Medicine have been the main enthusiasts for pay for performance. If they were serious about the quality of medical care, they might at least provide casual support for postgraduate education. Instead, postgraduate education remains the province of the pharmaceutical and device industries, which pay for at least 60% of these programs.
Long gone is the federal and academic support of postgraduate education. Instead, industry gets to set the educational agenda.
That agenda speaks to the increased use of new and expensive drugs and devices, which has a profound effect on increasing health care costs with marginal benefit to quality of care in a public health context.
Quality improvement has been the hallmark of the programs developed by the cardiology community and the ACC. In fact, improvements in the treatment and prevention of heart disease have comprised the major quality achievements of the past decade. They have been driven not by money, but by peer pressure and education. The quality standards that have been developed have gone a long way in decreasing hospital mortality.
The New York State coronary bypass surgery report-card system, instituted in 1989, has been the poster child of quality programs. The measurement and publication of mortality rates led to the establishment of benchmarks for performance and a significant decrease in bypass surgical mortality.
The establishment of quality standards for the treatment of myocardial infarction and heart failure has resulted in the incorporation of optimal standard therapy for discharge medication. At the same time, the establishment of optimal door-to-balloon time to angioplasty for ST-elevation myocardial infarctions remains under study but has already led to methodologies to achieve optimal time and improve infarct survival.
All of these initiatives have been led by the cardiology community and the ACC and were achieved by the profession without the onerous method of paying a doctor for better performance. The cardiology community has been at the forefront of quality initiatives, yet it was all scrapped when the ACC agreed to the Faustian deal of accepting pay for performance to prevent the 5% cut in physician pay. To do that, our representatives agreed to pay for quality rather than making it a professional duty.
So much for peer pressure and education to effect change. Now it's all in your paycheck.