Circulation: P4P may benefit docs who care for very sick

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Physicians who treat patients with multiple, co-existing, chronic health problems will fare well under pay-for-performance (P4P) initiatives, according to a report in the June 2 issue of Circulation.

When researchers from Baylor College of Medicine (BCM) and the Michael E. DeBakey Veterans Affairs (VA) Medical Center, both in Houston, evaluated the high blood pressure treatment provided to patients who had other serious health conditions, they found that such patients were more likely to receive high quality care than patients who had no co-existing health problems.

"Pay-for-performance raises a lot of fears and assumptions that the reimbursement will not be fair toward doctors who care for the sickest patients," said the study's lead author Laura A. Petersen, MD, director of the Houston VA Health Services Research and Development Center of Excellence and an associate professor of medicine at BCM. "What we found was that doctors do a good job of taking care of a lot of complex conditions, even better than they think they do."

Petersen, who is also chief of health services research at BCM, said the result surprised her. "When a patient comes in with many problems, there is often less time to address any single one," she said. However, she and her colleagues found that physicians appear to identify the problems that present the most risk and deal with them effectively.

"This is good news and should be reassuring to doctors and health policy makers," she said.

The research team chose to study high blood pressure because it is a common, symptomless problem that can have serious consequences, affecting the heart, brain and kidneys.

The researchers identified 141,609 patients with high blood pressure in a VA database. Of these, 22,595 had no other serious health conditions; 70,098 had conditions that could be related to the high blood pressure (concordant), 12,283 other health conditions not related to high blood pressure (discordant) and 36,633 had both.

Blood pressure was controlled for 57.3 percent of patients with no other health conditions, 64.7 percent of those with concordant or related health conditions and 63 percent of those with other conditions not related to blood pressure, according to the authors. Of those with both concordant and discordant condition, 69.2 percent had blood pressure controlled.

The researchers noted that quality of care increased with the number of other conditions. The sicker the patient, the better the care, even after statistically controlling for the number of visits with a doctor, the authors wrote.

"Our results should be reassuring for policy-makers who have faced criticism that performance measures, public reporting and pay-for-performance initiatives may penalize healthcare providers of patients with multiple co-existing chronic conditions," they wrote.

Funding for this work came from Department of VA, the National Institutes of Health (NIH), the Robert Wood Johnson Foundation and the American Heart Association (AHA).