Letters to the Editor - April 26, 2004

Pay-for-quality concept deserves to be judged on its merits - Take forward-looking approach in reducing nursing home liability risk - 20 years without liability coverage

Pay-for-quality concept deserves to be judged on its merits

Regarding "Fair pay a sounder approach than 'pay for quality' " (Column, March 1): AMA Board Chair William G. Plested III, MD, suggests in his column that there is little to be gained by linking compensation and performance in medicine. We would suggest that much has been lost by not doing so.

Research by the IOM, Rand Corp., Dartmouth, the National Committee for Quality Assurance and others supports the concept of pay for quality and rejects the status quo, which actually punishes quality by failing to reimburse for quality improvement efforts such as keeping a registry of patients with chronic conditions or reaching out to patients who need follow up. As sponsors and supporters of one of the largest pay-for-quality efforts -- the Bridges to Excellence initiative -- we believe that fair pay and pay for quality are not mutually exclusive. They can and must be the same thing.

We propose physicians ask the following questions to evaluate any such effort:

Were physicians involved in designing the program? Any successful effort will have physician input from the start.

How will performance and quality be measured? Any such effort should use adapted HEDIS or other such measures that are well tested, relevant and feasible. Performance thresholds must be readily available.

Will participating in the initiative help physicians improve their practices? Participating physicians should receive feedback on their performance on a regular basis. Physicians can and do use such feedback. It helps ensure better performance, and larger rewards, in the future.

What are the potential rewards? Available rewards should be sufficient to make the effort of participating worthwhile. Physicians participating in BTE can earn up to $20,000 per year in rewards and are recognized in selected network directories.

Is consideration given to risk-adjustment issues? BTE allows physicians to have their patient data risk-adjusted before it is scored by NCQA.

Are there any mechanisms in place to help physicians improve their practice and achieve the required performance levels? In particular, are county medical societies and quality improvement organizations involved in the effort and available to offer assistance?

But for space restrictions, this list could go on; we believe, however, that physicians are well-equipped to ask these questions and judge pay for quality on its merits. The alternative is simply to defend the status quo, in which good doctors get paid the same as those who don't measure up.

--Margaret E. O'Kane*, president, National Committee for Quality Assurance

--Thomas R. Reardon, MD*, former AMA president

--Joseph Newhouse, PhD*, John D. MacArthur professor, Harvard University

--Debra Ness*, executive vice president, National Partnership for Women and Families

--Jeff Hanson, treasurer, Bridges to Excellence

--Thomas H. Lee, MD, network president, Partners Healthcare System

--Francois De Brantes, program leader, health care initiatives, GE

--Helen Darling, president, National Business Group on Health

--Dale Whitney, corporate health care manager, United Parcel Service

--Russell Hoffman, MD, Louisville, Ky.

* Member of National Committee for Quality Assurance Board of Directors

Take forward-looking approach in reducing nursing home liability risk

Regarding "Tort crisis hits nursing homes" (Article, March 8): A number of steps can be taken to minimize the legal exposure in this area.

First and foremost, be sure to communicate directly with family members. Do not ask nursing home personnel to ask family members about clinical practice decisions such as the use of feeding tubes and medical interventions.

Second, family members tend not to be able to differentiate between negligent care and the aging process. This is particularly evident following a hip fracture or when a nursing home resident is unable to maintain nutrition because of cognitive or functional decline.

Third, direct the staff to notify you when significant changes in the resident's condition occur, such as the development of a pressure ulcer, weight loss, falls or behavioral issues.

Lastly, take time to read pertinent portions of the care plan, nursing monthly summaries, wound care flow sheets and dietitian's progress notes that ultimately impact upon your practice.

Since most nursing home malpractice actions involve pressure ulcers, malnutrition and falls, it is necessary to take proactive steps in addressing the needs of your residents as well as the education of their families.

--Ilene Warner-Maron, RN,

--Jeffrey J. Maron, DO, Media, Pa.

20 years without liability coverage

Regarding "Physicians weigh odds of going bare" (Article, April 5): I have been "bare" for 20 years. I charge $20 for an office visit. Don't take insurance, Medi-Cal or checks.

No appointments -- walk in and be seen. I see up to a 100 patients a day.

Now I am on the fourth generation of families in my truly family practice. Babies I delivered are having their babies. I think honesty and longevity are the best malpractice prevention techniques.

When you know that you will be seeing a patient all of your life, you must do your best.

The one time a lawyer probed and found out I don't carry malpractice, I never heard from him again.

Good luck to Dr. Mark Macumber, featured in your article.

--Ronald A. Grant, MD, Los Angeles