(Non)Pay for (Non)Performance

Posted onAuthorCedric Dark, MD, MPH, FACEP2 Comments

A recent Perspective in the New England Journal of Medicine explores Medicare’s plan to cease payments for 8 conditions – often reported as secondary diagnoses upon hospital discharge – that should never occur. Among these include: (1) objects left inside patients during surgery, (2) air embolism, (3) blood incompatibility, (4) pressure ulcers, (5) wound infection following heart bypass, (6) falls from bed, (7) catheter associated urinary tract infection (UTI), and (8) catheter associated blood infection.

As our health care payment system shifts from prospective payment to include pay-for-performance (P4P), this represents non-pay for non-performance and a strong incentive to ensure high quality nursing and medical practice. Certainly, most people can agree that these conditions should never occur. However, as with any P4P measure, the ability to accurately measure what you hope to – i.e. quality practices – is difficult.
Commentary:

How are we to know whether or not the patient who spikes a fever with either a UTI or positive blood culture on hospital day 2 or 3 was secondary to the medical intervention or to pre-existing conditions? These measures may have costly unintended consequences such as unnecessary urine or blood cultures drawn at the time of admission for every patient. While we can all agree that no patient should have a clamp accidentally left inside their body, or a develop pressure ulcers from poor nursing care, the Medicare program must be critical prior to adoption of P4P measures.

NEJM (2007) 357; 18: 1573.

2 Replies to “(Non)Pay for (Non)Performance”

  1. To be clear, we should not single out the mentally ill as a distraction from the real debate about gun safety and gun violence prevention. A person’s prior history of aggression is the biggest indicator for high-risk factors in committing future violence. That holds true for all people, not just the mentally ill.

  2. The employer mandate was intended more as a revenue measure than an enrollment tool. The direct revenue would come from employers that choose to pay fines rather than offer insurance.

    Indirectly, the mandate holds down federal costs for tax credits and subsidies by discouraging large employers from dropping insurance and dumping their employees into the marketplace. Many of these employees would qualify for assistance, thus driving up taxpayer costs.

    So, no, we don’t really need the employer mandate to drive enrollment. The individual mandate will presumably take care of that. But, eliminating the employer mandate will likely lead to higher federal spending for tax credits and subsidies.

    In that sense, this provision is like many others that ACA opponents want to eliminate. Getting rid of it may be attractive, but it will cost money.

Comments are closed.