Letters to the Editor - July 3, 2006

IVF reporting experiences foretell pay-for-performance problems - States' Medicaid healthy living push could be accomplished in better ways

IVF reporting experiences foretell pay-for-performance problems

Pay-for-performance is currently being examined as a method to reward physicians who provide quality and efficient patient care. A similar process has been practiced for years in the reproductive community and forecasts the problems that a pay-for-performance program will cause.

In 1994, the government required facilities that performed in vitro fertilization to report their statistical success rates. Published by the CDC, data were made available for patients to review worldwide in 1997.

Published data lagged behind submission dates by two to three years. Cutting-edge changes in our field could not be captured by the data. It often took years to modify the database to reflect the new procedures.

The reporting process caused some practices to begin to compete. Since delivery rates were the ultimate outcome measured, physicians began to transfer a greater number of quality embryos, resulting in both higher success rates and an undesired increase in the multiple pregnancy rates.

Practices caring for poor-prognosis patients were indirectly penalized through their lower published statistics. Access to health care decreased for the more complicated patients.

Patients used the statistics to compare facilities, although they often were not comparing like to like.

Lastly, the costs of a pay-for-performance program will be significant. Data entry alone will take a tremendous amount of time and employee hours.

Reproductive endocrinologists have been living with a similar system for almost nine years. With the inevitable delay of publication, failure to capture new procedures, decreased access for the complicated patients, the improper interpretation of the data and escalating reporting costs, pay-for-performance is doomed to meet its true goals.

I suspect that the issues that we faced in the past and continue to contend with now will confront my peers in other areas of medicine should pay-for-performance become a reality.

--Craig R. Sweet, MD, Fort Myers, Fla.

States' Medicaid healthy living push could be accomplished in better ways

Regarding "New law lets states get tough on benefits for Medicaid patients" (Article, June 12): Rewarding healthy lifestyles is absolutely the way to reduce health care costs in this country. However, I don't think the methods employed in Kentucky, West Virginia and Idaho are optimal:

1. It makes no sense to penalize children for the actions of their parents.

2. Restricting the number of medications covered per patient endangers patients' lives.

3. Penalties which are not financial (not covering diabetic education, nutritional education and tobacco cessation programs) are unlikely to motivate your average deadbeat.

4. A healthy lifestyle should not be defined by showing up for doctor visits and such. You can lead a healthy lifestyle and not be a compliant patient.

Here are some better ideas:

1. If you lead a healthy lifestyle, your co-pays for medications and doctor visits are lower.

2. A healthy lifestyle is defined in terms of objective measurements of weight loss and smoking cessation (absence of nicotine in the blood stream, for example).

3. Children are not included in the healthy lifestyle incentives.

--Matthew Gray Beckwith, MD, Hagerstown, Md.