ppp 06-11-07

Quote of the day: At work I am paid to be good…

at home my wife tells me I'm good for nothing.

Anon. Comedian

CMS has had a "pay for performance" study going on since 2003. The concept is that reimbursement of physicians and hospitals goes up as the patients under their care do better. (See article #1 below). The government picked 5 disease areas in which they wanted to measure outcomes improvement. It will not be long before pharmacists and other health professionals clamor for a "piece of the pie" related to pay for performance.
I believe that before anyone (government, managed care or private patients) is asked pay for enhanced pharmaceutical "performance" the "performance" should be defined. Both good and bad performance have to be defined... what should be measured and what is a good outcome. If actions are all that are measured and quantitated then this is no different than paying for counseling. If outcomes are the gold standard then goals must be defined, measurement tools must be defined and validated. How will the results of actions of the ultimate prescriber be able to be extracted from the results due to actions of the pharmacists? I believe that it is impossible to separate the prescriber and the pharmacist. Prescribers may be able to act independently and profit or lose by the way in which they provide care. As much as pharmacists like to believe that they are independent practitioners they can, at best, be members of a team.
           To demonstrate the difference in outcomes between a sole prescriber and one who is aided by a pharmacist would involve large control groups where pharmacists are not part of the care system. More than a little effort has already been expended showing the differences in practice models.
           "Who gets the money" has always been a part of these discussion. If the employer (hospital, pharmacy, clinic) gets the money then there is no monitory incentive for the pharmacist. If the pharmacist gets the money then should the employer reduce salary for the time taken to counsel? With present pharmacist salaries, charging anything less than $2 per minute of the pharmacist's time makes counseling a "loss leader".
           The question of whether or not pharmacists make a measurable and reimbursable difference has been rattling around since the words "clinical" and "pharmacist" were used together over 30 years ago. What is new is that anyone would consider paying physicians for "performance" and that some pharmacists are asking "What's in it for me?" I really don't see pharmacists purposefully doing a worse job for non reimbursed patients as they do for the paying customers. In many cases I have seen the patients who generate the least revenue and the highest expenses also consume the most non-reimbursed pharmacist time. Given additional resources we may be able to do "good things" for more patients but I doubt that the "good things" will be "better things" than we already strive to do.
            Just my opinion... I could be wrong!

ps. Best answer this week to the question "How are you?" was "I woke up on the right side of the dirt!" (a respiratory therapist's clever variation on "every day above ground is a good one!")

pps. Occasionally, some of the links require FREE registration.... I'm sure you can handle THAT slight inconvenience.

1) Pay for non-performance
Each group of patients did about the same whether the hospital was receiving additional incentive reimbursement or not. It could just be that physicians want to do what is best for their patients in spite of the amount they get paid. What a concept!
http://online.wsj.com/article_print/SB118108165080625550.html

2) Less pay for any performance?
The rate of Medicare reimbursement will soon decline. Physicians warm that care will not decline but be cut off as fewer physicians accept Medicare patients. The other "trick" is for physicians to shift more patients to the inpatient setting where the money come out of a different bucket. All buckets are filled by the taxpayers… so does it really matter? … Yes! It matters because inpatient care is even more expensive that outpatient care.
http://today.reuters.com/news/articlenews.

3) Playing House with drug safety.
The Senate passed a drug safety bill last month and the House will soon take up this issue. Watch for curbs on direct to consumer advertising and other items which will have to be negotiated in conference committee.
http://yahoo.reuters.com/news/as&rpc=44

4) I had my head examined…. they found nothing.
Early tests may predict Alzheimer's disease. When existing drugs will only slow the process (not reverse it) it appears to be more prudent to detect early and treat, Maybe some new drugs will be discovered that will reverse the damage but I do not hold out much hope for my lifetime. You just can't unscramble an egg.
http://www.reuters.com/article/healthNews/idUSN1039377020070610

6) The no-zone.
The Fed wants all multidose inhalers using CFCs off of the market starting in 2009. Expect other propellants to be put in place soon (many drug companies have been moving that direction for years). Abbott and Boehringer to be most effected.
http://www.bloomberg.com/apps/news?pid=20601202&sid=agFnGlxyUUcw&refer=healthcare

7) Mystic moth moves market memory marvelously
The Luna moth used in the Lunesta TV ads makes the biggest impression of consumers related to new drugs ads. (Yes it is a moth and NOT A BUTTERFLY). This is keeping Abe Lincoln, the beaver and the astronaut up nights.
http://www.iagr.net/pr_060507.jsp

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