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Sunday, July 23, 2006

Perverse Incentives: Pfizer is having a good year thanks to cholesterol lowering drugs. At the same time, insurance companies are experimenting with the "pay for performance" model. One of those experiments involves rewarding doctors for keeping their patients' cholesterol levels below defined guidelines. Cholesterol is an easy benchmark to measure and to collect, but the guidelines themselves are not without controversy. Rumor has it that some doctors with a large populations of cholesterol-targeted patients, such as cardiologists, are receiving bonuses in the 5-figure range. At least one news account appears to confirm this.

That's a hefty incentive to get those cholesterol numbers down as low as possible. How do you suppose they achieve the goals? By educating and encouraging lifestyle modification - i.e. diet and exercise? Not likely. That's too time consuming and patient-dependent. A drug, or two, or three will reward the doctor with stellar lab results, though it might penalize the patient in drug costs and side effects. And what if the patient complains that their muscles ache every since they've been taking those three cholesterol medications? He'll get a pat on the back and an admonition to bear with it. "Which would you rather have, a heart attack or achey muscles?"

Pay-for-performance - a boondoggle for physicians and the pharmaceutical industry, but little benefit to the patient or the insurance industry. How long will it take before insurance companies figure out it's costing them more than it's saving them?

posted by sydney on 7/23/2006 09:10:00 AM 14 comments

14 Comments:

Off topic

Damn! You're back. If I'd known I'd've been reading.

By Dave Schuler, at 7:43 PM

Great to see your back!
As a patient I've been worried about the same thing with P4P -- pressure on patients to take preventive drugs/do all popular preventive measures without honest information about benefits/risks. Even if the NNT for most of these preventive measures is in the thousands.

What annoys me about the cholesterol guidelines is that they a) make no difference between male/female -- I am yet to have a doctor show me any convincing evidence of benefit for primary prevention in women b) don't appear to consider the person's absolute risk (or think that less than 1% in ARR worth putting a healthy person on lifetime drugs) c) appear to throw informed consent out of the window: I am yet to see a doctor who use absolute risk reduction or NNT to describe the benefit -- surely different people may have different opinion on whether for them 2 or 3 percentage points in ARR worth taking drugs? Shouldn't they be given accurate information to make an informed choice? d) ignore the fact that healthy symptomless people taking a drug to prevent a small chance of something happening in future are much less tolerant of side effects now than those who seek relief from symptoms. I am afraid P4P will make this much worse. At least now doctors don't care if you say "no, thanks". With P4P they might waste precious office time trying to convince you.

My doctor wanted to put me on statins - my LDL was 4 points above the number mentioned in the guidelines for my risk factors. My HDL was fine, my ratio was fine, my triglicerides were low. I am a slim and active female in my 40s and according to the calculator on AHA web site my 10-year risk of heart attack is under 1%. I did some research and told "no, thanks". I did get my LDL down by adding making some changes to my diet, but it is beside the point. Even if I hadn't, is less than 1 percentage point in ARR worth putting a healthy person on life time drugs that may have side effects?

By Diora, at 10:35 AM

My experience resembles that of Diora. On my first visit to a now past doctor the first comment was: "We have to get you medicated so we can get you in here more often." This was followed for a big pitch for statins. No blood draws, no questions, just here is the med.

Everyone should be aware that $39B of drugs ae going off patient in the next couple of years. Big Pharma is going to push like crazy to get us all medicated to keep that cash flow, so don't be surprised if more drugs are hyped as preventive medicine, regardless of need.

Steve Lucas

By Anonymous, at 2:47 PM

Wow, this post is upsetting to me.

By Dr. Deborah Serani, at 10:40 AM

Just had a discussion about P4P with one of my collaborating physicians (a cardiologist) that included how pt compliance affects achieving benchmark goals. She joked, "it's not like we have depot statins" for those who don't take their meds.

By CardioNP, at 12:53 AM

Corrections: $39B of drugs ae going off patient, should read $39B of drugs are going generic.

Steve Lucas

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By Anonymous, at 3:02 PM

If the financial rewards for hitting pay-for-performance goals are large, do you think it may encourage doctors to dump patients who are ruining their stats? Or to avoid taking on new patients who seem likely to hurt their numbers?

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