Timothy F. Kirn

SEATTLE — Patients who undergo a laparoscopic procedure for colon or rectal cancer have no worse mortality beyond 5 years than those who have an open procedure, according to a prospective, randomized trial presented at the annual meeting of the American Society of Colon and Rectal Surgeons.

“We found no unusual recurrences after a median follow-up of over 7 years, and there were no wound recurrences in our laparoscopy group,” Dr. Daniel P. Geisler said in reference to the follow-up results of his 110-patient trial at the Cleveland Clinic.

No previous prospective studies of laparoscopy and colon cancer have reported postsurgical results beyond 3 years, said Dr. Geisler of the colorectal surgery department at the Cleveland Clinic. His study, with a median follow-up of 7.5 years, found overall survival rates of 82% for the 55 patients whose cancer was removed laparoscopically, and 67% for the 55 patients who underwent a conventional procedure—a difference that was not statistically significant, Dr. Geisler said.

Cancer-related survival by cancer stage was 82% for stage I (92% for laparoscopy vs. 86% for conventional), 83% for stage II (93% laparoscopy vs. 73% for conventional), 69% for stage III (67% laparoscopy vs. 70% conventional), and 0% for stage IV.

The patients in the trial were undergoing curative resective procedures for cancer or polyps of the right colon, sigmoid colon, or upper or lower rectum. Patients who turned out to have benign disease after surgery (15 patients in each randomized group) were excluded from further follow-up.

There was no difference between groups in age, gender, or overall health. They had similar distribution by postoperative staging, similar numbers of nodes removed (an average of 21 for laparoscopy versus 25 for conventional), and equivalent resection margins.

The laparoscopic procedures that were done in the mid-1990s took significantly longer to perform, but hospital stays were shorter (an average of 6 days vs. 7 days for those patients undergoing the open procedure).

The laparoscopic patients also needed less analgesia after the procedure than the open group (an average of 0.8 mg/kg of morphine equivalent on the first postoperative day vs. 1 mg/kg, with no difference on subsequent days). The laparoscopic group had a more rapid return to normal pulmonary function (a return to 80% of their preoperative function at an average of 3 days vs. 6 days for the open surgery patients).

A total of 11% of the laparoscopic procedures were converted to open procedures. But the postoperative complication rate was the same for both groups (15%). There was one death in each group within 30 days. One wound recurred, in a patient who had a conventional procedure.

Given the short-term benefits, the trial suggests laparoscopy is the preferred approach, Dr. Geisler said.

Asked to compare the laparoscopic procedures with an open procedure with an epidural, Dr. Geisler said that an epidural provides better pain coverage during open procedures, but he would still favor a laparoscopic procedure because no epidural is needed, so the immediate postoperative recovery is much shorter.

Given the short-term benefits, the trial data suggest that laparoscopy is the preferred approach. DR. GEISLER

SEATTLE — Patients who undergo a laparoscopic procedure for colon or rectal cancer have no worse mortality beyond 5 years than those who have an open procedure, according to a prospective, randomized trial presented at the annual meeting of the American Society of Colon and Rectal Surgeons.

“We found no unusual recurrences after a median follow-up of over 7 years, and there were no wound recurrences in our laparoscopy group,” Dr. Daniel P. Geisler said in reference to the follow-up results of his 110-patient trial at the Cleveland Clinic.

No previous prospective studies of laparoscopy and colon cancer have reported postsurgical results beyond 3 years, said Dr. Geisler of the colorectal surgery department at the Cleveland Clinic. His study, with a median follow-up of 7.5 years, found overall survival rates of 82% for the 55 patients whose cancer was removed laparoscopically, and 67% for the 55 patients who underwent a conventional procedure—a difference that was not statistically significant, Dr. Geisler said.

Cancer-related survival by cancer stage was 82% for stage I (92% for laparoscopy vs. 86% for conventional), 83% for stage II (93% laparoscopy vs. 73% for conventional), 69% for stage III (67% laparoscopy vs. 70% conventional), and 0% for stage IV.

The patients in the trial were undergoing curative resective procedures for cancer or polyps of the right colon, sigmoid colon, or upper or lower rectum. Patients who turned out to have benign disease after surgery (15 patients in each randomized group) were excluded from further follow-up.

There was no difference between groups in age, gender, or overall health. They had similar distribution by postoperative staging, similar numbers of nodes removed (an average of 21 for laparoscopy versus 25 for conventional), and equivalent resection margins.

The laparoscopic procedures that were done in the mid-1990s took significantly longer to perform, but hospital stays were shorter (an average of 6 days vs. 7 days for those patients undergoing the open procedure).

The laparoscopic patients also needed less analgesia after the procedure than the open group (an average of 0.8 mg/kg of morphine equivalent on the first postoperative day vs. 1 mg/kg, with no difference on subsequent days). The laparoscopic group had a more rapid return to normal pulmonary function (a return to 80% of their preoperative function at an average of 3 days vs. 6 days for the open surgery patients).

A total of 11% of the laparoscopic procedures were converted to open procedures. But the postoperative complication rate was the same for both groups (15%). There was one death in each group within 30 days. One wound recurred, in a patient who had a conventional procedure.

Given the short-term benefits, the trial suggests laparoscopy is the preferred approach, Dr. Geisler said.

Asked to compare the laparoscopic procedures with an open procedure with an epidural, Dr. Geisler said that an epidural provides better pain coverage during open procedures, but he would still favor a laparoscopic procedure because no epidural is needed, so the immediate postoperative recovery is much shorter.

Given the short-term benefits, the trial data suggest that laparoscopy is the preferred approach. DR. GEISLER

SEATTLE — Patients who undergo a laparoscopic procedure for colon or rectal cancer have no worse mortality beyond 5 years than those who have an open procedure, according to a prospective, randomized trial presented at the annual meeting of the American Society of Colon and Rectal Surgeons.

“We found no unusual recurrences after a median follow-up of over 7 years, and there were no wound recurrences in our laparoscopy group,” Dr. Daniel P. Geisler said in reference to the follow-up results of his 110-patient trial at the Cleveland Clinic.

No previous prospective studies of laparoscopy and colon cancer have reported postsurgical results beyond 3 years, said Dr. Geisler of the colorectal surgery department at the Cleveland Clinic. His study, with a median follow-up of 7.5 years, found overall survival rates of 82% for the 55 patients whose cancer was removed laparoscopically, and 67% for the 55 patients who underwent a conventional procedure—a difference that was not statistically significant, Dr. Geisler said.

Cancer-related survival by cancer stage was 82% for stage I (92% for laparoscopy vs. 86% for conventional), 83% for stage II (93% laparoscopy vs. 73% for conventional), 69% for stage III (67% laparoscopy vs. 70% conventional), and 0% for stage IV.

The patients in the trial were undergoing curative resective procedures for cancer or polyps of the right colon, sigmoid colon, or upper or lower rectum. Patients who turned out to have benign disease after surgery (15 patients in each randomized group) were excluded from further follow-up.

There was no difference between groups in age, gender, or overall health. They had similar distribution by postoperative staging, similar numbers of nodes removed (an average of 21 for laparoscopy versus 25 for conventional), and equivalent resection margins.

The laparoscopic procedures that were done in the mid-1990s took significantly longer to perform, but hospital stays were shorter (an average of 6 days vs. 7 days for those patients undergoing the open procedure).

The laparoscopic patients also needed less analgesia after the procedure than the open group (an average of 0.8 mg/kg of morphine equivalent on the first postoperative day vs. 1 mg/kg, with no difference on subsequent days). The laparoscopic group had a more rapid return to normal pulmonary function (a return to 80% of their preoperative function at an average of 3 days vs. 6 days for the open surgery patients).

A total of 11% of the laparoscopic procedures were converted to open procedures. But the postoperative complication rate was the same for both groups (15%). There was one death in each group within 30 days. One wound recurred, in a patient who had a conventional procedure.

Given the short-term benefits, the trial suggests laparoscopy is the preferred approach, Dr. Geisler said.

Asked to compare the laparoscopic procedures with an open procedure with an epidural, Dr. Geisler said that an epidural provides better pain coverage during open procedures, but he would still favor a laparoscopic procedure because no epidural is needed, so the immediate postoperative recovery is much shorter.

Given the short-term benefits, the trial data suggest that laparoscopy is the preferred approach. DR. GEISLER

SEATTLE — Patients taking antidepressants and cholesterol-lowering drugs who are in pharmacy-capped plans, such as the new Medicare Part D drug benefit, often stop taking their drugs when they reach the cap, Geoffrey Joyce, Ph.D., said at the annual research meeting of Academy Health.

According to his research, anywhere from 6% to 11% of patients in the Medicare Part D program are likely to hit what is known as the "doughnut hole" of coverage in any given year, according to Dr. Joyce, who serves as a senior economist with the RAND Corp., Santa Monica, Calif.

The so-called doughnut hole is the gap in coverage that goes into effect during a coverage year when a patient's drug expenditures reach $2,250, and continues until the expenditures reach $5,100.

Prior to reaching the doughnut-hole gap, Medicare Part D beneficiaries have a $250 annual deductible and pay 25% of their drug costs.

After expenditures have reached $5,100, catastrophic coverage kicks in and patients pay only 5% of costs.

But within the doughnut hole, patients pay 100% of their drug costs.

Many health economists and others have worried that the Medicare Part D patients most likely to spend their way into the doughnut hole are the sickest patients, and that those patients might become noncompliant with their medication regimens when they surpass their $2,250 limit.

Dr. Joyce and his colleagues looked at two employer health plans with drug benefits that had a cap on coverage of $2,500, in order to get an idea of what is likely to happen with the Medicare plan.

In the years considered (2003 and 2004), 7% of beneficiaries in one plan and 11% in the other plan hit the cap.

The median time of year when patients hit the cap was September. However, one quarter of the patients who hit the cap did so in June, meaning they had no drug coverage for a full 6 months, Dr. Joyce said.

Patients did not appear to switch from brand-name drugs to generic drugs in any appreciable degree when they reached the cap. However, some patients did stop taking certain drugs.

The most common medications the patients stopped taking were antidepressants and cholesterol-lowering medications, the RAND investigators found.

One factor that proved most concerning about those who stopped taking their medication was that only about 40% of those who stopped then restarted those drugs at the beginning of the new year, Dr. Joyce said.

Previous studies of drug benefit caps have shown that they do reduce plan costs significantly.

In one study of a Kaiser Permanente plan, for example, a cap resulted in drug costs that were 31% lower.

That study also found, however, that there may be a price to pay for curtailing drug benefits too drastically, according to Dr. Joyce.

Overall, the Kaiser study found that the capped plan did not result in higher medical care costs. But there were more hospitalizations and more emergency department visits in the capped plan, compared to a noncapped plan.

That study also found that there was also a 22% higher mortality among patients in the capped plan.

Given the higher hospitalization and emergency department visit rates among these patients, the finding that medical-care costs were no higher is probably a statistical anomaly, and is not accurate, Dr. Joyce said.

In the RAND Corp. study, Dr. Joyce said the investigators have begun looking at ancillary costs that might be associated with the failure of patients to fill prescriptions that they otherwise would have filled.

That analysis is not yet completed, according to Dr. Joyce.

SEATTLE — Patients taking antidepressants and cholesterol-lowering drugs who are in pharmacy-capped plans, such as the new Medicare Part D drug benefit, often stop taking their drugs when they reach the cap, Geoffrey Joyce, Ph.D., said at the annual research meeting of Academy Health.

According to his research, anywhere from 6% to 11% of patients in the Medicare Part D program are likely to hit what is known as the "doughnut hole" of coverage in any given year, according to Dr. Joyce, who serves as a senior economist with the RAND Corp., Santa Monica, Calif.

The so-called doughnut hole is the gap in coverage that goes into effect during a coverage year when a patient's drug expenditures reach $2,250, and continues until the expenditures reach $5,100.

Prior to reaching the doughnut-hole gap, Medicare Part D beneficiaries have a $250 annual deductible and pay 25% of their drug costs.

After expenditures have reached $5,100, catastrophic coverage kicks in and patients pay only 5% of costs.

But within the doughnut hole, patients pay 100% of their drug costs.

Many health economists and others have worried that the Medicare Part D patients most likely to spend their way into the doughnut hole are the sickest patients, and that those patients might become noncompliant with their medication regimens when they surpass their $2,250 limit.

Dr. Joyce and his colleagues looked at two employer health plans with drug benefits that had a cap on coverage of $2,500, in order to get an idea of what is likely to happen with the Medicare plan.

In the years considered (2003 and 2004), 7% of beneficiaries in one plan and 11% in the other plan hit the cap.

The median time of year when patients hit the cap was September. However, one quarter of the patients who hit the cap did so in June, meaning they had no drug coverage for a full 6 months, Dr. Joyce said.

Patients did not appear to switch from brand-name drugs to generic drugs in any appreciable degree when they reached the cap. However, some patients did stop taking certain drugs.

The most common medications the patients stopped taking were antidepressants and cholesterol-lowering medications, the RAND investigators found.

One factor that proved most concerning about those who stopped taking their medication was that only about 40% of those who stopped then restarted those drugs at the beginning of the new year, Dr. Joyce said.

Previous studies of drug benefit caps have shown that they do reduce plan costs significantly.

In one study of a Kaiser Permanente plan, for example, a cap resulted in drug costs that were 31% lower.

That study also found, however, that there may be a price to pay for curtailing drug benefits too drastically, according to Dr. Joyce.

Overall, the Kaiser study found that the capped plan did not result in higher medical care costs. But there were more hospitalizations and more emergency department visits in the capped plan, compared to a noncapped plan.

That study also found that there was also a 22% higher mortality among patients in the capped plan.

Given the higher hospitalization and emergency department visit rates among these patients, the finding that medical-care costs were no higher is probably a statistical anomaly, and is not accurate, Dr. Joyce said.

In the RAND Corp. study, Dr. Joyce said the investigators have begun looking at ancillary costs that might be associated with the failure of patients to fill prescriptions that they otherwise would have filled.

That analysis is not yet completed, according to Dr. Joyce.

SEATTLE — Patients taking antidepressants and cholesterol-lowering drugs who are in pharmacy-capped plans, such as the new Medicare Part D drug benefit, often stop taking their drugs when they reach the cap, Geoffrey Joyce, Ph.D., said at the annual research meeting of Academy Health.

According to his research, anywhere from 6% to 11% of patients in the Medicare Part D program are likely to hit what is known as the "doughnut hole" of coverage in any given year, according to Dr. Joyce, who serves as a senior economist with the RAND Corp., Santa Monica, Calif.

The so-called doughnut hole is the gap in coverage that goes into effect during a coverage year when a patient's drug expenditures reach $2,250, and continues until the expenditures reach $5,100.

Prior to reaching the doughnut-hole gap, Medicare Part D beneficiaries have a $250 annual deductible and pay 25% of their drug costs.

After expenditures have reached $5,100, catastrophic coverage kicks in and patients pay only 5% of costs.

But within the doughnut hole, patients pay 100% of their drug costs.

Many health economists and others have worried that the Medicare Part D patients most likely to spend their way into the doughnut hole are the sickest patients, and that those patients might become noncompliant with their medication regimens when they surpass their $2,250 limit.

Dr. Joyce and his colleagues looked at two employer health plans with drug benefits that had a cap on coverage of $2,500, in order to get an idea of what is likely to happen with the Medicare plan.

In the years considered (2003 and 2004), 7% of beneficiaries in one plan and 11% in the other plan hit the cap.

The median time of year when patients hit the cap was September. However, one quarter of the patients who hit the cap did so in June, meaning they had no drug coverage for a full 6 months, Dr. Joyce said.

Patients did not appear to switch from brand-name drugs to generic drugs in any appreciable degree when they reached the cap. However, some patients did stop taking certain drugs.

The most common medications the patients stopped taking were antidepressants and cholesterol-lowering medications, the RAND investigators found.

One factor that proved most concerning about those who stopped taking their medication was that only about 40% of those who stopped then restarted those drugs at the beginning of the new year, Dr. Joyce said.

Previous studies of drug benefit caps have shown that they do reduce plan costs significantly.

In one study of a Kaiser Permanente plan, for example, a cap resulted in drug costs that were 31% lower.

That study also found, however, that there may be a price to pay for curtailing drug benefits too drastically, according to Dr. Joyce.

Overall, the Kaiser study found that the capped plan did not result in higher medical care costs. But there were more hospitalizations and more emergency department visits in the capped plan, compared to a noncapped plan.

That study also found that there was also a 22% higher mortality among patients in the capped plan.

Given the higher hospitalization and emergency department visit rates among these patients, the finding that medical-care costs were no higher is probably a statistical anomaly, and is not accurate, Dr. Joyce said.

In the RAND Corp. study, Dr. Joyce said the investigators have begun looking at ancillary costs that might be associated with the failure of patients to fill prescriptions that they otherwise would have filled.

That analysis is not yet completed, according to Dr. Joyce.

SEATTLE — When the physicians of Rochester, N.Y., first had a pay-for-performance program imposed upon them, they ignored it.

"At the beginning of our program, most people would not acknowledge it existed," said Dr. Howard B. Beckman, the medical director of the Rochester Individual Physician Association (IPA). "As we talked about the profiles, people said 'I never got them,' 'I threw them away,' or 'I don't care.'"

That denial ended when the first performance-based checks were disbursed, and after 3 years, pay-for-performance measures have paid off in reduced health plan costs of almost $5 million, Dr. Beckman said at the annual research meeting of AcademyHealth.

Dr. Beckman was one of three physicians who presented research on whether pay for performance improves quality of care and efficiency in medicine enough to make worthwhile all the effort being put into it. He was the only one of the three to have a positive conclusion.

The other two investigations of pay for performance, in California and Massachusetts, looked more specifically at individual aspects of clinical care. Those investigators found they could not document an impact from the programs.

But those investigators also pointed out that, as in Rochester, it takes time for physicians to get accustomed to the idea of greater accountability, and to develop the capabilities to record and report for the programs, so their findings might reflect that the programs have not been going long enough. Or the findings may show that financial incentives do not work for professionals, something research in other fields has suggested, they noted.

After the first performance bonus checks were sent out and denial ended, there was anger. The physicians complained that strict performance measures impinge on their autonomy, and they were even offended by the implication that money could influence their behavior, he said.

Then, after 2 years, the general resistance abated, and the angry phone calls stopped, Dr. Beckman said. Now when he gets phone calls about the program, it is an individual physician trying to negotiate something.

The Rochester IPA represents all 3,200 physicians in the Rochester area and has insurance contracts that cover about 50% of the community market.

The program's individual physician payments vary, but overall the program pays out about $15 million a year, and the average internist can earn from $4,000 to $12,000 from the quality reports. Dr. Beckman looked at the provider profile data for patients with diabetes. He found that when expected costs were compared with actual costs in the diabetes patients in 2003 and 2004, there was a savings of about $1 million in the first year and $2 million in the second year. Most of that savings, about $1.3 million, came from reduced inpatient hospitalization costs.

Dr. Beckman pointed out that many people have expressed concern that pay-for-performance programs could be unfair to physicians with the most difficult, least compliant patients, so he looked at different practices. It appeared that differences were greater between individual doctors than they were between practices and practice locations.

Pay for performance began in California at about the same time as the Rochester program, and it has yet to show any meaningful overall improvement in clinical care, said Cheryl L. Damberg, Ph.D., a researcher for the RAND Corp. who has been analyzing data from the California collaborative managed by the Integrated Healthcare Association, which includes seven HMOs and point-of-service plans contracting with 225 physician groups.

Surveys of patient satisfaction, a part of performance that is rewarded, showed gradual, substantive improvement in the first 2 years of the program, but when Dr. Damberg looked at clinical care measures, such as aspects of diabetes care, Pap smears, and childhood immunization, any improvement seen between years is inconsistent and varied.

She concluded, based on an analysis of the patterns of improvement, that many physicians and groups are getting up to speed with reporting, so it is too early to judge the impact on actual clinical care.

In Massachusetts, doctors with pay-for-performance contracts have improved their quality since programs were introduced into the state, but so have doctors without contracts, said Dr. Steven D. Pearson, director of the Center for Ethics in Managed Care at Harvard Medical School, Boston.

He looked at data collected from the state's pay-for-performance programs put together by the Massachusetts Health Quality Partnership, a collaboration of five nonprofit health plans covering 4 million people, and physician groups representing some 5,000 primary care physicians.

Comparing Health Plan Employer Data and Information Set measures from groups with pay-for-performance contracts and control groups without contracts, Dr. Pearson found that, for four measures, the contract groups had more improvement for those years than the control groups. For 21 measures, the groups had similar improvement, but for five measures the control groups had more improvement.

Moreover, when he restricted his analysis to just groups termed "high-incentive" groups, there was still no more improvement than controls. High-incentive groups were defined as ones that could receive performance bonuses of $100,000 or more, or for whom individual primary care physicians could receive bonuses of more than $1,000.

There are two plausible explanations for the findings, Dr. Pearson said. "Either P4P has worked in Massachusetts because it is part of this atmosphere of driving quality improvement … or P4P has failed because it is either too weak—not enough money on the table—or it was poorly designed."

Fragmented Care Poses Dilemma For P4P System

Pay-for-performance schemes may be thwarted by patients seeing too many doctors, making it difficult to assign any one patient's care to a particular physician, according to a study that was presented at the annual research meeting of AcademyHealth.

The average Medicare patient sees seven physicians (two primary care, five specialists) over a 2-year period, Dr. Hoangmai Pham, a senior researcher with the Center for Studying Health System Change, Washington, said at the meeting.

Dr. Pham analyzed data from Medicare sources that included claims data and nationwide physician surveys for 2000–2003. Only 53% of Medicare beneficiaries' evaluation and management visits, and 35% of their total visits, are with the physician identified as their primary, or usual-source-of-care, physician.

During a 2-year period, 30% of beneficiaries switch their usual-source-of-care physician, and in 59% of the cases where beneficiaries switch, they never even see one of the designated physicians in a year, Dr. Pham said.

According to the physician survey data, a primary care physician's regular, usual-source-of-care patients make up an average of only 39% of his or her total patient population.

In today's medical environment, it takes more than one doctor to care for a patient, Dr. Pham said.

The Department of Health and Human Services has committed the Medicare program to advancing the concept of pay for performance, Dr. Pham noted. But what is really needed is an overhaul of the medical system to allow single physicians or groups to be responsible for individual patients. Alternatively, more financial incentive in pay for performance would make it worthwhile to invest in the infrastructure physicians need to participate, because they will be able to show good performance for only a small proportion of their patients, she added.

SEATTLE — When the physicians of Rochester, N.Y., first had a pay-for-performance program imposed upon them, they ignored it.

"At the beginning of our program, most people would not acknowledge it existed," said Dr. Howard B. Beckman, the medical director of the Rochester Individual Physician Association (IPA). "As we talked about the profiles, people said 'I never got them,' 'I threw them away,' or 'I don't care.'"

That denial ended when the first performance-based checks were disbursed, and after 3 years, pay-for-performance measures have paid off in reduced health plan costs of almost $5 million, Dr. Beckman said at the annual research meeting of AcademyHealth.

Dr. Beckman was one of three physicians who presented research on whether pay for performance improves quality of care and efficiency in medicine enough to make worthwhile all the effort being put into it. He was the only one of the three to have a positive conclusion.

The other two investigations of pay for performance, in California and Massachusetts, looked more specifically at individual aspects of clinical care. Those investigators found they could not document an impact from the programs.

But those investigators also pointed out that, as in Rochester, it takes time for physicians to get accustomed to the idea of greater accountability, and to develop the capabilities to record and report for the programs, so their findings might reflect that the programs have not been going long enough. Or the findings may show that financial incentives do not work for professionals, something research in other fields has suggested, they noted.

After the first performance bonus checks were sent out and denial ended, there was anger. The physicians complained that strict performance measures impinge on their autonomy, and they were even offended by the implication that money could influence their behavior, he said.

Then, after 2 years, the general resistance abated, and the angry phone calls stopped, Dr. Beckman said. Now when he gets phone calls about the program, it is an individual physician trying to negotiate something.

The Rochester IPA represents all 3,200 physicians in the Rochester area and has insurance contracts that cover about 50% of the community market.

The program's individual physician payments vary, but overall the program pays out about $15 million a year, and the average internist can earn from $4,000 to $12,000 from the quality reports. Dr. Beckman looked at the provider profile data for patients with diabetes. He found that when expected costs were compared with actual costs in the diabetes patients in 2003 and 2004, there was a savings of about $1 million in the first year and $2 million in the second year. Most of that savings, about $1.3 million, came from reduced inpatient hospitalization costs.

Dr. Beckman pointed out that many people have expressed concern that pay-for-performance programs could be unfair to physicians with the most difficult, least compliant patients, so he looked at different practices. It appeared that differences were greater between individual doctors than they were between practices and practice locations.

Pay for performance began in California at about the same time as the Rochester program, and it has yet to show any meaningful overall improvement in clinical care, said Cheryl L. Damberg, Ph.D., a researcher for the RAND Corp. who has been analyzing data from the California collaborative managed by the Integrated Healthcare Association, which includes seven HMOs and point-of-service plans contracting with 225 physician groups.

Surveys of patient satisfaction, a part of performance that is rewarded, showed gradual, substantive improvement in the first 2 years of the program, but when Dr. Damberg looked at clinical care measures, such as aspects of diabetes care, Pap smears, and childhood immunization, any improvement seen between years is inconsistent and varied.

She concluded, based on an analysis of the patterns of improvement, that many physicians and groups are getting up to speed with reporting, so it is too early to judge the impact on actual clinical care.

In Massachusetts, doctors with pay-for-performance contracts have improved their quality since programs were introduced into the state, but so have doctors without contracts, said Dr. Steven D. Pearson, director of the Center for Ethics in Managed Care at Harvard Medical School, Boston.

He looked at data collected from the state's pay-for-performance programs put together by the Massachusetts Health Quality Partnership, a collaboration of five nonprofit health plans covering 4 million people, and physician groups representing some 5,000 primary care physicians.

Comparing Health Plan Employer Data and Information Set measures from groups with pay-for-performance contracts and control groups without contracts, Dr. Pearson found that, for four measures, the contract groups had more improvement for those years than the control groups. For 21 measures, the groups had similar improvement, but for five measures the control groups had more improvement.

Moreover, when he restricted his analysis to just groups termed "high-incentive" groups, there was still no more improvement than controls. High-incentive groups were defined as ones that could receive performance bonuses of $100,000 or more, or for whom individual primary care physicians could receive bonuses of more than $1,000.

There are two plausible explanations for the findings, Dr. Pearson said. "Either P4P has worked in Massachusetts because it is part of this atmosphere of driving quality improvement … or P4P has failed because it is either too weak—not enough money on the table—or it was poorly designed."

Fragmented Care Poses Dilemma For P4P System

Pay-for-performance schemes may be thwarted by patients seeing too many doctors, making it difficult to assign any one patient's care to a particular physician, according to a study that was presented at the annual research meeting of AcademyHealth.

The average Medicare patient sees seven physicians (two primary care, five specialists) over a 2-year period, Dr. Hoangmai Pham, a senior researcher with the Center for Studying Health System Change, Washington, said at the meeting.

Dr. Pham analyzed data from Medicare sources that included claims data and nationwide physician surveys for 2000–2003. Only 53% of Medicare beneficiaries' evaluation and management visits, and 35% of their total visits, are with the physician identified as their primary, or usual-source-of-care, physician.

During a 2-year period, 30% of beneficiaries switch their usual-source-of-care physician, and in 59% of the cases where beneficiaries switch, they never even see one of the designated physicians in a year, Dr. Pham said.

According to the physician survey data, a primary care physician's regular, usual-source-of-care patients make up an average of only 39% of his or her total patient population.

In today's medical environment, it takes more than one doctor to care for a patient, Dr. Pham said.

The Department of Health and Human Services has committed the Medicare program to advancing the concept of pay for performance, Dr. Pham noted. But what is really needed is an overhaul of the medical system to allow single physicians or groups to be responsible for individual patients. Alternatively, more financial incentive in pay for performance would make it worthwhile to invest in the infrastructure physicians need to participate, because they will be able to show good performance for only a small proportion of their patients, she added.

SEATTLE — When the physicians of Rochester, N.Y., first had a pay-for-performance program imposed upon them, they ignored it.

"At the beginning of our program, most people would not acknowledge it existed," said Dr. Howard B. Beckman, the medical director of the Rochester Individual Physician Association (IPA). "As we talked about the profiles, people said 'I never got them,' 'I threw them away,' or 'I don't care.'"

That denial ended when the first performance-based checks were disbursed, and after 3 years, pay-for-performance measures have paid off in reduced health plan costs of almost $5 million, Dr. Beckman said at the annual research meeting of AcademyHealth.

Dr. Beckman was one of three physicians who presented research on whether pay for performance improves quality of care and efficiency in medicine enough to make worthwhile all the effort being put into it. He was the only one of the three to have a positive conclusion.

The other two investigations of pay for performance, in California and Massachusetts, looked more specifically at individual aspects of clinical care. Those investigators found they could not document an impact from the programs.

But those investigators also pointed out that, as in Rochester, it takes time for physicians to get accustomed to the idea of greater accountability, and to develop the capabilities to record and report for the programs, so their findings might reflect that the programs have not been going long enough. Or the findings may show that financial incentives do not work for professionals, something research in other fields has suggested, they noted.

After the first performance bonus checks were sent out and denial ended, there was anger. The physicians complained that strict performance measures impinge on their autonomy, and they were even offended by the implication that money could influence their behavior, he said.

Then, after 2 years, the general resistance abated, and the angry phone calls stopped, Dr. Beckman said. Now when he gets phone calls about the program, it is an individual physician trying to negotiate something.

The Rochester IPA represents all 3,200 physicians in the Rochester area and has insurance contracts that cover about 50% of the community market.

The program's individual physician payments vary, but overall the program pays out about $15 million a year, and the average internist can earn from $4,000 to $12,000 from the quality reports. Dr. Beckman looked at the provider profile data for patients with diabetes. He found that when expected costs were compared with actual costs in the diabetes patients in 2003 and 2004, there was a savings of about $1 million in the first year and $2 million in the second year. Most of that savings, about $1.3 million, came from reduced inpatient hospitalization costs.

Dr. Beckman pointed out that many people have expressed concern that pay-for-performance programs could be unfair to physicians with the most difficult, least compliant patients, so he looked at different practices. It appeared that differences were greater between individual doctors than they were between practices and practice locations.

Pay for performance began in California at about the same time as the Rochester program, and it has yet to show any meaningful overall improvement in clinical care, said Cheryl L. Damberg, Ph.D., a researcher for the RAND Corp. who has been analyzing data from the California collaborative managed by the Integrated Healthcare Association, which includes seven HMOs and point-of-service plans contracting with 225 physician groups.

Surveys of patient satisfaction, a part of performance that is rewarded, showed gradual, substantive improvement in the first 2 years of the program, but when Dr. Damberg looked at clinical care measures, such as aspects of diabetes care, Pap smears, and childhood immunization, any improvement seen between years is inconsistent and varied.

She concluded, based on an analysis of the patterns of improvement, that many physicians and groups are getting up to speed with reporting, so it is too early to judge the impact on actual clinical care.

In Massachusetts, doctors with pay-for-performance contracts have improved their quality since programs were introduced into the state, but so have doctors without contracts, said Dr. Steven D. Pearson, director of the Center for Ethics in Managed Care at Harvard Medical School, Boston.

He looked at data collected from the state's pay-for-performance programs put together by the Massachusetts Health Quality Partnership, a collaboration of five nonprofit health plans covering 4 million people, and physician groups representing some 5,000 primary care physicians.

Comparing Health Plan Employer Data and Information Set measures from groups with pay-for-performance contracts and control groups without contracts, Dr. Pearson found that, for four measures, the contract groups had more improvement for those years than the control groups. For 21 measures, the groups had similar improvement, but for five measures the control groups had more improvement.

Moreover, when he restricted his analysis to just groups termed "high-incentive" groups, there was still no more improvement than controls. High-incentive groups were defined as ones that could receive performance bonuses of $100,000 or more, or for whom individual primary care physicians could receive bonuses of more than $1,000.

There are two plausible explanations for the findings, Dr. Pearson said. "Either P4P has worked in Massachusetts because it is part of this atmosphere of driving quality improvement … or P4P has failed because it is either too weak—not enough money on the table—or it was poorly designed."

Fragmented Care Poses Dilemma For P4P System

Pay-for-performance schemes may be thwarted by patients seeing too many doctors, making it difficult to assign any one patient's care to a particular physician, according to a study that was presented at the annual research meeting of AcademyHealth.

The average Medicare patient sees seven physicians (two primary care, five specialists) over a 2-year period, Dr. Hoangmai Pham, a senior researcher with the Center for Studying Health System Change, Washington, said at the meeting.

Dr. Pham analyzed data from Medicare sources that included claims data and nationwide physician surveys for 2000–2003. Only 53% of Medicare beneficiaries' evaluation and management visits, and 35% of their total visits, are with the physician identified as their primary, or usual-source-of-care, physician.

During a 2-year period, 30% of beneficiaries switch their usual-source-of-care physician, and in 59% of the cases where beneficiaries switch, they never even see one of the designated physicians in a year, Dr. Pham said.

According to the physician survey data, a primary care physician's regular, usual-source-of-care patients make up an average of only 39% of his or her total patient population.

In today's medical environment, it takes more than one doctor to care for a patient, Dr. Pham said.

The Department of Health and Human Services has committed the Medicare program to advancing the concept of pay for performance, Dr. Pham noted. But what is really needed is an overhaul of the medical system to allow single physicians or groups to be responsible for individual patients. Alternatively, more financial incentive in pay for performance would make it worthwhile to invest in the infrastructure physicians need to participate, because they will be able to show good performance for only a small proportion of their patients, she added.

SEATTLE — Patients taking antidepressants and cholesterol-lowering drugs who are in pharmacy-capped plans, like the new Medicare Part D drug benefit, often stop taking their drugs when they reach the cap, Geoffrey Joyce, Ph.D., said at the annual research meeting of Academy Health.

According to his research, anywhere from 6% to 11% of patients in the Medicare Part D program are likely to hit what is known as the “doughnut hole” of coverage in any given year, said Dr. Joyce, a senior economist with the RAND Corp., Santa Monica, Calif.

The so-called doughnut hole is the gap in coverage that goes into effect during a coverage year when a patient's drug expenditures reach $2,250, and continues until the expenditures reach $5,100. Prior to reaching the doughnut-hole gap, beneficiaries have a $250 annual deductible and pay 25% of their drug costs. After expenditures have reached $5,100, catastrophic coverage kicks in and patients pay only 5% of costs. Within the doughnut hole, patients pay 100% of their drug costs.

Many health economists and others have worried that the Medicare Part D patients most likely to spend their way into the doughnut hole are the sickest patients, and that those patients might become noncompliant with their medication regimens when they surpass their $2,250 limit.

Dr. Joyce and colleagues looked at two employer health plans with drug benefits that had a cap on coverage of $2,500, in order to get an idea of what is likely to happen with the Medicare plan.

In the years considered (2003 and 2004), 7% of beneficiaries in one plan and 11% in the other plan hit the cap.

The median time of year when patients hit the cap was September. However, one quarter of the patients who hit the cap did so in June, meaning they had no drug coverage for a full 6 months, Dr. Joyce said.

Patients did not appear to switch from brand-name drugs to generic drugs in any appreciable degree when they reached the cap. However, some patients did stop taking certain drugs. The most common medications the patients stopped taking were antidepressants and cholesterol-lowering drugs.

What was most concerning about those who stopped was that only about 40% of those who stopped then restarted those drugs at the beginning of the new year, Dr. Joyce said.

Previous studies of drug benefit caps have shown that they do reduce plan costs significantly. In one study of a Kaiser Permanente plan, a cap resulted in 31% lower drug costs.

That study found, however, that there may be a price to pay for curtailing drug benefits too drastically, Dr. Joyce noted.

Overall, the Kaiser study found that the capped plan did not result in higher medical care costs. But there were more hospitalizations and more emergency department visits in the capped plan, compared to a noncapped plan. There was also a 22% higher mortality among patients in the capped plan.

Given the higher hospitalization and ED visit rates, the finding that medical-care costs were no higher is probably a statistical anomaly, and is not accurate, Dr. Joyce said.

In this study, the investigators have begun looking at ancillary costs that might be associated with patients' not filling prescriptions they otherwise would have filled. But that work is not completed yet.

SEATTLE — Patients taking antidepressants and cholesterol-lowering drugs who are in pharmacy-capped plans, like the new Medicare Part D drug benefit, often stop taking their drugs when they reach the cap, Geoffrey Joyce, Ph.D., said at the annual research meeting of Academy Health.

According to his research, anywhere from 6% to 11% of patients in the Medicare Part D program are likely to hit what is known as the “doughnut hole” of coverage in any given year, said Dr. Joyce, a senior economist with the RAND Corp., Santa Monica, Calif.

The so-called doughnut hole is the gap in coverage that goes into effect during a coverage year when a patient's drug expenditures reach $2,250, and continues until the expenditures reach $5,100. Prior to reaching the doughnut-hole gap, beneficiaries have a $250 annual deductible and pay 25% of their drug costs. After expenditures have reached $5,100, catastrophic coverage kicks in and patients pay only 5% of costs. Within the doughnut hole, patients pay 100% of their drug costs.

Many health economists and others have worried that the Medicare Part D patients most likely to spend their way into the doughnut hole are the sickest patients, and that those patients might become noncompliant with their medication regimens when they surpass their $2,250 limit.

Dr. Joyce and colleagues looked at two employer health plans with drug benefits that had a cap on coverage of $2,500, in order to get an idea of what is likely to happen with the Medicare plan.

In the years considered (2003 and 2004), 7% of beneficiaries in one plan and 11% in the other plan hit the cap.

The median time of year when patients hit the cap was September. However, one quarter of the patients who hit the cap did so in June, meaning they had no drug coverage for a full 6 months, Dr. Joyce said.

Patients did not appear to switch from brand-name drugs to generic drugs in any appreciable degree when they reached the cap. However, some patients did stop taking certain drugs. The most common medications the patients stopped taking were antidepressants and cholesterol-lowering drugs.

What was most concerning about those who stopped was that only about 40% of those who stopped then restarted those drugs at the beginning of the new year, Dr. Joyce said.

Previous studies of drug benefit caps have shown that they do reduce plan costs significantly. In one study of a Kaiser Permanente plan, a cap resulted in 31% lower drug costs.

That study found, however, that there may be a price to pay for curtailing drug benefits too drastically, Dr. Joyce noted.

Overall, the Kaiser study found that the capped plan did not result in higher medical care costs. But there were more hospitalizations and more emergency department visits in the capped plan, compared to a noncapped plan. There was also a 22% higher mortality among patients in the capped plan.

Given the higher hospitalization and ED visit rates, the finding that medical-care costs were no higher is probably a statistical anomaly, and is not accurate, Dr. Joyce said.

In this study, the investigators have begun looking at ancillary costs that might be associated with patients' not filling prescriptions they otherwise would have filled. But that work is not completed yet.

SEATTLE — Patients taking antidepressants and cholesterol-lowering drugs who are in pharmacy-capped plans, like the new Medicare Part D drug benefit, often stop taking their drugs when they reach the cap, Geoffrey Joyce, Ph.D., said at the annual research meeting of Academy Health.

According to his research, anywhere from 6% to 11% of patients in the Medicare Part D program are likely to hit what is known as the “doughnut hole” of coverage in any given year, said Dr. Joyce, a senior economist with the RAND Corp., Santa Monica, Calif.

The so-called doughnut hole is the gap in coverage that goes into effect during a coverage year when a patient's drug expenditures reach $2,250, and continues until the expenditures reach $5,100. Prior to reaching the doughnut-hole gap, beneficiaries have a $250 annual deductible and pay 25% of their drug costs. After expenditures have reached $5,100, catastrophic coverage kicks in and patients pay only 5% of costs. Within the doughnut hole, patients pay 100% of their drug costs.

Many health economists and others have worried that the Medicare Part D patients most likely to spend their way into the doughnut hole are the sickest patients, and that those patients might become noncompliant with their medication regimens when they surpass their $2,250 limit.

Dr. Joyce and colleagues looked at two employer health plans with drug benefits that had a cap on coverage of $2,500, in order to get an idea of what is likely to happen with the Medicare plan.

In the years considered (2003 and 2004), 7% of beneficiaries in one plan and 11% in the other plan hit the cap.

The median time of year when patients hit the cap was September. However, one quarter of the patients who hit the cap did so in June, meaning they had no drug coverage for a full 6 months, Dr. Joyce said.

Patients did not appear to switch from brand-name drugs to generic drugs in any appreciable degree when they reached the cap. However, some patients did stop taking certain drugs. The most common medications the patients stopped taking were antidepressants and cholesterol-lowering drugs.

What was most concerning about those who stopped was that only about 40% of those who stopped then restarted those drugs at the beginning of the new year, Dr. Joyce said.

Previous studies of drug benefit caps have shown that they do reduce plan costs significantly. In one study of a Kaiser Permanente plan, a cap resulted in 31% lower drug costs.

That study found, however, that there may be a price to pay for curtailing drug benefits too drastically, Dr. Joyce noted.

Overall, the Kaiser study found that the capped plan did not result in higher medical care costs. But there were more hospitalizations and more emergency department visits in the capped plan, compared to a noncapped plan. There was also a 22% higher mortality among patients in the capped plan.

Given the higher hospitalization and ED visit rates, the finding that medical-care costs were no higher is probably a statistical anomaly, and is not accurate, Dr. Joyce said.

In this study, the investigators have begun looking at ancillary costs that might be associated with patients' not filling prescriptions they otherwise would have filled. But that work is not completed yet.

SEATTLE — Nearly half of a sample of elderly persons in Los Angeles were given medications that they probably should not have been taking, and the problem rose sharply with the number of prescriptions, Gretchen E. Alkema said at the annual research meeting of AcademyHealth.

Among elderly persons who were taking 12 or more medications, 70% had one or more medication problems, and among those taking 7–9 medications, 50% had one or more medication problems.

The elderly frequently end up being given a medication that they shouldn't be using or being given too many medications, said Ms. Alkema of the Davis School of Gerontology at the University of Southern California, Los Angeles, in a poster presentation.

The study looked at a cohort of 615 individuals in a Medicaid waiver program. The subjects were living at home but were at risk for institutionalization. Their average age was 80 years, about 40% were living alone, and 60% spoke English.

A pharmacist reviewed their medications, looking for four types of medication problems: unnecessary therapeutic duplication, inappropriate psychotropic medication, cardiovascular medication problems, and inappropriate NSAID use. Overall, 49% had one medication problem, 19% had two medication problems, and 5% had three or more problems.

The most common type of problem was therapeutic duplication, followed by inappropriate psychotropic use and cardiovascular medication problems. One important risk factor associated with medication error was that the individual had been to a hospital, emergency department, or skilled nursing facility in the past year. Those contacts with the medical system doubled the risk of a problem.

SEATTLE — Nearly half of a sample of elderly persons in Los Angeles were given medications that they probably should not have been taking, and the problem rose sharply with the number of prescriptions, Gretchen E. Alkema said at the annual research meeting of AcademyHealth.

Among elderly persons who were taking 12 or more medications, 70% had one or more medication problems, and among those taking 7–9 medications, 50% had one or more medication problems.

The elderly frequently end up being given a medication that they shouldn't be using or being given too many medications, said Ms. Alkema of the Davis School of Gerontology at the University of Southern California, Los Angeles, in a poster presentation.

The study looked at a cohort of 615 individuals in a Medicaid waiver program. The subjects were living at home but were at risk for institutionalization. Their average age was 80 years, about 40% were living alone, and 60% spoke English.

A pharmacist reviewed their medications, looking for four types of medication problems: unnecessary therapeutic duplication, inappropriate psychotropic medication, cardiovascular medication problems, and inappropriate NSAID use. Overall, 49% had one medication problem, 19% had two medication problems, and 5% had three or more problems.

The most common type of problem was therapeutic duplication, followed by inappropriate psychotropic use and cardiovascular medication problems. One important risk factor associated with medication error was that the individual had been to a hospital, emergency department, or skilled nursing facility in the past year. Those contacts with the medical system doubled the risk of a problem.

SEATTLE — Nearly half of a sample of elderly persons in Los Angeles were given medications that they probably should not have been taking, and the problem rose sharply with the number of prescriptions, Gretchen E. Alkema said at the annual research meeting of AcademyHealth.

Among elderly persons who were taking 12 or more medications, 70% had one or more medication problems, and among those taking 7–9 medications, 50% had one or more medication problems.

The elderly frequently end up being given a medication that they shouldn't be using or being given too many medications, said Ms. Alkema of the Davis School of Gerontology at the University of Southern California, Los Angeles, in a poster presentation.

The study looked at a cohort of 615 individuals in a Medicaid waiver program. The subjects were living at home but were at risk for institutionalization. Their average age was 80 years, about 40% were living alone, and 60% spoke English.

A pharmacist reviewed their medications, looking for four types of medication problems: unnecessary therapeutic duplication, inappropriate psychotropic medication, cardiovascular medication problems, and inappropriate NSAID use. Overall, 49% had one medication problem, 19% had two medication problems, and 5% had three or more problems.

The most common type of problem was therapeutic duplication, followed by inappropriate psychotropic use and cardiovascular medication problems. One important risk factor associated with medication error was that the individual had been to a hospital, emergency department, or skilled nursing facility in the past year. Those contacts with the medical system doubled the risk of a problem.

SEATTLE — When the physicians of Rochester, N.Y., first had a pay-for-performance program imposed on them, they ignored it.

“At the beginning of our program, most people would not acknowledge it existed,” said Dr. Howard B. Beckman, the medical director of the Rochester Individual Physician Association (IPA). “As we talked about the profiles, people said 'I never got them,' 'I threw them away,' or 'I don't care.'”

That denial ended when the first performance-based checks were disbursed, and after 3 years, pay-for-performance measures have paid off in reduced health plan costs of almost $5 million, Dr. Beckman said at the annual research meeting of AcademyHealth.

Dr. Beckman was one of three physicians who presented research on whether pay for performance improves quality of care and efficiency in medicine enough to make worthwhile all the effort being put into it. He was the only one of the three to have a positive conclusion.

The other two investigations of pay for performance, in California and Massachusetts, looked more specifically at individual aspects of clinical care. Those investigators found they could not document an impact from the programs.

But those investigators also pointed out that, as in Rochester, it takes time for physicians to get accustomed to the idea of greater accountability, and to develop the capabilities to record and report for the programs, so their findings might reflect the fact that the programs have not been going long enough.

On the other hand, the findings may show that financial incentives do not work for professionals, something research in other fields has suggested, they noted.

The Rochester physicians went through stages of acceptance of pay for performance not unlike the stages of grief defined by Dr. Elisabeth Kübler-Ross, Dr. Beckman said.

After the first performance bonus checks were sent out and denial ended, there was anger. The physicians complained that strict performance measures impinge on their autonomy, and they were even offended by the implication that money could influence their behavior, he said.

Then, after about 2 years, the general resistance abated, and the angry phone calls stopped, Dr. Beckman said. Now when he gets phone calls about the program, it is an individual physician trying to negotiate something.

The Rochester IPA represents all 3,200 physicians in the Rochester area and has insurance contracts that cover about 50% of the community market. Its individual physician profiling program began in 2002.

The program's individual physician payments vary, but overall the program pays out about $15 million a year, and the average internist can earn from $4,000 to $12,000 from the quality reports. The physicians get three reports a year, and payments are made at the end of the year.

Dr. Beckman looked at the provider profile data for patients with diabetes and coronary artery disease. He found that when expected costs were compared with actual costs in the diabetes patients in 2003 and 2004, there was a savings of about $1 million in the first year and $2 million in the second year. Most of that savings, about $1.3 million, came from reduced inpatient hospitalization costs.

The savings for the coronary artery disease patients was about $2 million over the 2 years, for a total savings for just those two groups of patients of about $5 million, Dr. Beckman said. Given what the group had put into the program (about $1.1 million, mostly for computer capability), the return on investment for the program was about four times what was spent.

Dr. Beckman pointed out that many people have expressed concern that pay-for-performance programs could be unfair to physicians with the most difficult, least compliant patients, so he looked at different practices. It appeared that differences were greater between individual doctors than they were between practices and practice locations.

Pay for performance began in California at about the same time as the Rochester program, and it has yet to show any meaningful overall improvement in clinical care, said Cheryl L. Damberg, Ph.D., a researcher for the RAND Corp., who has been analyzing data from the California collaborative managed by the Integrated Healthcare Association, which includes seven HMOs and point-of-service plans contracting with 225 physician groups.

Surveys of patient satisfaction, a part of performance that is rewarded, showed gradual, substantive improvement in the first 2 years of the program. But when Dr. Damberg looked at clinical care measures, such as aspects of diabetes care, Pap smears, and childhood immunization, any improvement seen between years is inconsistent and varied.

She concluded, based on an analysis of the patterns of improvement, that many physicians and groups are getting up to speed with reporting, so it is too early to judge the impact on actual clinical care.

“Some areas have seen more dramatic improvement than others,” she added. But “this is not the dramatic breakthrough we are all looking for to close the quality chasms.”

In Massachusetts, doctors with pay-for-performance contracts have improved their quality since programs were introduced into the state, but so have doctors without contracts, said Dr. Steven D. Pearson, the director of the Center for Ethics in Managed Care at Harvard Medical School, Boston.

He looked at data collected from the state's pay-for-performance programs put together by the Massachusetts Health Quality Partnership, a collaboration of five nonprofit health plans covering 4 million people, and physician groups representing some 5,000 primary care physicians.

In 2001, there were four pay-for-performance contracts in the state. That rose to 8 in 2002, and 18 in 2003.

Comparing Health Plan Employer Data and Information Set measures from the groups with those contracts to measures from control groups without contracts, Dr. Pearson found that, for 4 of 30 measures, the contract groups had more improvement for those years than the control groups. For 21 measures, the groups had similar improvement.

But, for five measures—chlamydia testing, hemoglobin A_1c testing in diabetics, LDL testing in diabetics, urine testing in diabetics, and well-child visits by adolescents—the control groups had more improvement. And, two of the four measures for which the contract groups outperformed the control groups were dominated by a special contract and a single 38-physician practice, Dr. Pearson said.

Moreover, when he restricted his analysis to just groups termed “high-incentive” groups, there was still no more improvement than controls. High-incentive groups were defined as ones that could receive performance bonuses of $100,000 or more, or for whom individual primary care physicians could receive bonuses of more than $1,000.

There are two plausible explanations for the findings, Dr. Pearson said. “Either P4P has worked in Massachusetts because it is part of this atmosphere of driving quality improvement … or P4P has failed because it is either too weak—not enough money on the table—or it was poorly designed.”

Money indeed may turn out to be the pressing issue as pay for performance becomes more common.

Slowly but surely, many physicians seem to be coming around to pay for performance because they see it as an effort in medicine to make quality a priority, these investigators said.

But Dr. Damberg said California groups have told her they want to “see more skin in the game” to help them recoup the investments they have had to make to adapt to the programs. If it doesn't come, she is afraid they will lose patience.

“It is really still too early to declare victory or defeat for pay for performance,” Dr. Damberg concluded. “These programs take a while to stabilize.

“It's really important to look at these over a much longer time frame because people move through different stages of engagement, denial, or whatever label you want to put on it,” she added.

Fragmented Care Creates a Problem for Pay-for-Performance Plans, Study Says

Pay-for-performance schemes may be thwarted by patients seeing too many doctors, making it difficult to assign any one patient's care to a particular physician, according to a study presented at the annual research meeting of AcademyHealth.

The average Medicare patient sees seven physicians (two primary care, five specialists) over a 2-year period, Dr. Hoangmai Pham, a senior researcher with the Center for Studying Health System Change, Washington, said at the meeting.

Dr. Pham analyzed data from a number of Medicare sources to come to her conclusion. These sources included claims data and nationwide physician surveys for 2000–2003.

Not only do patients see a number of physicians, but their main physician may not even see them the majority of the time; they also switch their primary provider often.

Only 53% of Medicare beneficiaries' evaluation and management visits, and 35% of their total visits, are with the physician identified as their primary, or usual-source-of-care, physician.

During a 2-year period, 30% of beneficiaries switch their usual-source-of-care physician, and in 59% of the cases where beneficiaries switch, they never even see one of the designated physicians in a year, Dr. Pham said.

According to the physician survey data, a primary care physician's regular, usual-source-of-care patients make up an average of only 39% of his or her total patient population.

These figures show that in today's medical environment, it takes more than one doctor to care for a patient, Dr. Pham said.

The Department of Health and Human Services has committed the Medicare program to advancing the concept of pay for performance, Dr. Pham noted.

But what is really needed is an overhaul of the way the medical system is organized to allow single physicians or groups to actually be responsible for individual patients. Or, alternatively, there needs to be more financial incentive in pay for performance to make it worthwhile for physicians to invest in the infrastructure they need to participate, because they are going to be able to show good performance for only a small proportion of their patients, she added.

SEATTLE — When the physicians of Rochester, N.Y., first had a pay-for-performance program imposed on them, they ignored it.

“At the beginning of our program, most people would not acknowledge it existed,” said Dr. Howard B. Beckman, the medical director of the Rochester Individual Physician Association (IPA). “As we talked about the profiles, people said 'I never got them,' 'I threw them away,' or 'I don't care.'”

That denial ended when the first performance-based checks were disbursed, and after 3 years, pay-for-performance measures have paid off in reduced health plan costs of almost $5 million, Dr. Beckman said at the annual research meeting of AcademyHealth.

Dr. Beckman was one of three physicians who presented research on whether pay for performance improves quality of care and efficiency in medicine enough to make worthwhile all the effort being put into it. He was the only one of the three to have a positive conclusion.

The other two investigations of pay for performance, in California and Massachusetts, looked more specifically at individual aspects of clinical care. Those investigators found they could not document an impact from the programs.

But those investigators also pointed out that, as in Rochester, it takes time for physicians to get accustomed to the idea of greater accountability, and to develop the capabilities to record and report for the programs, so their findings might reflect the fact that the programs have not been going long enough.

On the other hand, the findings may show that financial incentives do not work for professionals, something research in other fields has suggested, they noted.

The Rochester physicians went through stages of acceptance of pay for performance not unlike the stages of grief defined by Dr. Elisabeth Kübler-Ross, Dr. Beckman said.

After the first performance bonus checks were sent out and denial ended, there was anger. The physicians complained that strict performance measures impinge on their autonomy, and they were even offended by the implication that money could influence their behavior, he said.

Then, after about 2 years, the general resistance abated, and the angry phone calls stopped, Dr. Beckman said. Now when he gets phone calls about the program, it is an individual physician trying to negotiate something.

The Rochester IPA represents all 3,200 physicians in the Rochester area and has insurance contracts that cover about 50% of the community market. Its individual physician profiling program began in 2002.

The program's individual physician payments vary, but overall the program pays out about $15 million a year, and the average internist can earn from $4,000 to $12,000 from the quality reports. The physicians get three reports a year, and payments are made at the end of the year.

Dr. Beckman looked at the provider profile data for patients with diabetes and coronary artery disease. He found that when expected costs were compared with actual costs in the diabetes patients in 2003 and 2004, there was a savings of about $1 million in the first year and $2 million in the second year. Most of that savings, about $1.3 million, came from reduced inpatient hospitalization costs.

The savings for the coronary artery disease patients was about $2 million over the 2 years, for a total savings for just those two groups of patients of about $5 million, Dr. Beckman said. Given what the group had put into the program (about $1.1 million, mostly for computer capability), the return on investment for the program was about four times what was spent.

Dr. Beckman pointed out that many people have expressed concern that pay-for-performance programs could be unfair to physicians with the most difficult, least compliant patients, so he looked at different practices. It appeared that differences were greater between individual doctors than they were between practices and practice locations.

Pay for performance began in California at about the same time as the Rochester program, and it has yet to show any meaningful overall improvement in clinical care, said Cheryl L. Damberg, Ph.D., a researcher for the RAND Corp., who has been analyzing data from the California collaborative managed by the Integrated Healthcare Association, which includes seven HMOs and point-of-service plans contracting with 225 physician groups.

Surveys of patient satisfaction, a part of performance that is rewarded, showed gradual, substantive improvement in the first 2 years of the program. But when Dr. Damberg looked at clinical care measures, such as aspects of diabetes care, Pap smears, and childhood immunization, any improvement seen between years is inconsistent and varied.

She concluded, based on an analysis of the patterns of improvement, that many physicians and groups are getting up to speed with reporting, so it is too early to judge the impact on actual clinical care.

“Some areas have seen more dramatic improvement than others,” she added. But “this is not the dramatic breakthrough we are all looking for to close the quality chasms.”

In Massachusetts, doctors with pay-for-performance contracts have improved their quality since programs were introduced into the state, but so have doctors without contracts, said Dr. Steven D. Pearson, the director of the Center for Ethics in Managed Care at Harvard Medical School, Boston.

He looked at data collected from the state's pay-for-performance programs put together by the Massachusetts Health Quality Partnership, a collaboration of five nonprofit health plans covering 4 million people, and physician groups representing some 5,000 primary care physicians.

In 2001, there were four pay-for-performance contracts in the state. That rose to 8 in 2002, and 18 in 2003.

Comparing Health Plan Employer Data and Information Set measures from the groups with those contracts to measures from control groups without contracts, Dr. Pearson found that, for 4 of 30 measures, the contract groups had more improvement for those years than the control groups. For 21 measures, the groups had similar improvement.

But, for five measures—chlamydia testing, hemoglobin A_1c testing in diabetics, LDL testing in diabetics, urine testing in diabetics, and well-child visits by adolescents—the control groups had more improvement. And, two of the four measures for which the contract groups outperformed the control groups were dominated by a special contract and a single 38-physician practice, Dr. Pearson said.

Moreover, when he restricted his analysis to just groups termed “high-incentive” groups, there was still no more improvement than controls. High-incentive groups were defined as ones that could receive performance bonuses of $100,000 or more, or for whom individual primary care physicians could receive bonuses of more than $1,000.

There are two plausible explanations for the findings, Dr. Pearson said. “Either P4P has worked in Massachusetts because it is part of this atmosphere of driving quality improvement … or P4P has failed because it is either too weak—not enough money on the table—or it was poorly designed.”

Money indeed may turn out to be the pressing issue as pay for performance becomes more common.

Slowly but surely, many physicians seem to be coming around to pay for performance because they see it as an effort in medicine to make quality a priority, these investigators said.

But Dr. Damberg said California groups have told her they want to “see more skin in the game” to help them recoup the investments they have had to make to adapt to the programs. If it doesn't come, she is afraid they will lose patience.

“It is really still too early to declare victory or defeat for pay for performance,” Dr. Damberg concluded. “These programs take a while to stabilize.

“It's really important to look at these over a much longer time frame because people move through different stages of engagement, denial, or whatever label you want to put on it,” she added.

Fragmented Care Creates a Problem for Pay-for-Performance Plans, Study Says

Pay-for-performance schemes may be thwarted by patients seeing too many doctors, making it difficult to assign any one patient's care to a particular physician, according to a study presented at the annual research meeting of AcademyHealth.

The average Medicare patient sees seven physicians (two primary care, five specialists) over a 2-year period, Dr. Hoangmai Pham, a senior researcher with the Center for Studying Health System Change, Washington, said at the meeting.

Dr. Pham analyzed data from a number of Medicare sources to come to her conclusion. These sources included claims data and nationwide physician surveys for 2000–2003.

Not only do patients see a number of physicians, but their main physician may not even see them the majority of the time; they also switch their primary provider often.

Only 53% of Medicare beneficiaries' evaluation and management visits, and 35% of their total visits, are with the physician identified as their primary, or usual-source-of-care, physician.

During a 2-year period, 30% of beneficiaries switch their usual-source-of-care physician, and in 59% of the cases where beneficiaries switch, they never even see one of the designated physicians in a year, Dr. Pham said.

According to the physician survey data, a primary care physician's regular, usual-source-of-care patients make up an average of only 39% of his or her total patient population.

These figures show that in today's medical environment, it takes more than one doctor to care for a patient, Dr. Pham said.

The Department of Health and Human Services has committed the Medicare program to advancing the concept of pay for performance, Dr. Pham noted.

But what is really needed is an overhaul of the way the medical system is organized to allow single physicians or groups to actually be responsible for individual patients. Or, alternatively, there needs to be more financial incentive in pay for performance to make it worthwhile for physicians to invest in the infrastructure they need to participate, because they are going to be able to show good performance for only a small proportion of their patients, she added.

SEATTLE — When the physicians of Rochester, N.Y., first had a pay-for-performance program imposed on them, they ignored it.

“At the beginning of our program, most people would not acknowledge it existed,” said Dr. Howard B. Beckman, the medical director of the Rochester Individual Physician Association (IPA). “As we talked about the profiles, people said 'I never got them,' 'I threw them away,' or 'I don't care.'”

That denial ended when the first performance-based checks were disbursed, and after 3 years, pay-for-performance measures have paid off in reduced health plan costs of almost $5 million, Dr. Beckman said at the annual research meeting of AcademyHealth.

Dr. Beckman was one of three physicians who presented research on whether pay for performance improves quality of care and efficiency in medicine enough to make worthwhile all the effort being put into it. He was the only one of the three to have a positive conclusion.

The other two investigations of pay for performance, in California and Massachusetts, looked more specifically at individual aspects of clinical care. Those investigators found they could not document an impact from the programs.

But those investigators also pointed out that, as in Rochester, it takes time for physicians to get accustomed to the idea of greater accountability, and to develop the capabilities to record and report for the programs, so their findings might reflect the fact that the programs have not been going long enough.

On the other hand, the findings may show that financial incentives do not work for professionals, something research in other fields has suggested, they noted.

The Rochester physicians went through stages of acceptance of pay for performance not unlike the stages of grief defined by Dr. Elisabeth Kübler-Ross, Dr. Beckman said.

After the first performance bonus checks were sent out and denial ended, there was anger. The physicians complained that strict performance measures impinge on their autonomy, and they were even offended by the implication that money could influence their behavior, he said.

Then, after about 2 years, the general resistance abated, and the angry phone calls stopped, Dr. Beckman said. Now when he gets phone calls about the program, it is an individual physician trying to negotiate something.

The Rochester IPA represents all 3,200 physicians in the Rochester area and has insurance contracts that cover about 50% of the community market. Its individual physician profiling program began in 2002.

The program's individual physician payments vary, but overall the program pays out about $15 million a year, and the average internist can earn from $4,000 to $12,000 from the quality reports. The physicians get three reports a year, and payments are made at the end of the year.

Dr. Beckman looked at the provider profile data for patients with diabetes and coronary artery disease. He found that when expected costs were compared with actual costs in the diabetes patients in 2003 and 2004, there was a savings of about $1 million in the first year and $2 million in the second year. Most of that savings, about $1.3 million, came from reduced inpatient hospitalization costs.

The savings for the coronary artery disease patients was about $2 million over the 2 years, for a total savings for just those two groups of patients of about $5 million, Dr. Beckman said. Given what the group had put into the program (about $1.1 million, mostly for computer capability), the return on investment for the program was about four times what was spent.

Dr. Beckman pointed out that many people have expressed concern that pay-for-performance programs could be unfair to physicians with the most difficult, least compliant patients, so he looked at different practices. It appeared that differences were greater between individual doctors than they were between practices and practice locations.

Pay for performance began in California at about the same time as the Rochester program, and it has yet to show any meaningful overall improvement in clinical care, said Cheryl L. Damberg, Ph.D., a researcher for the RAND Corp., who has been analyzing data from the California collaborative managed by the Integrated Healthcare Association, which includes seven HMOs and point-of-service plans contracting with 225 physician groups.

Surveys of patient satisfaction, a part of performance that is rewarded, showed gradual, substantive improvement in the first 2 years of the program. But when Dr. Damberg looked at clinical care measures, such as aspects of diabetes care, Pap smears, and childhood immunization, any improvement seen between years is inconsistent and varied.

She concluded, based on an analysis of the patterns of improvement, that many physicians and groups are getting up to speed with reporting, so it is too early to judge the impact on actual clinical care.

“Some areas have seen more dramatic improvement than others,” she added. But “this is not the dramatic breakthrough we are all looking for to close the quality chasms.”

In Massachusetts, doctors with pay-for-performance contracts have improved their quality since programs were introduced into the state, but so have doctors without contracts, said Dr. Steven D. Pearson, the director of the Center for Ethics in Managed Care at Harvard Medical School, Boston.

He looked at data collected from the state's pay-for-performance programs put together by the Massachusetts Health Quality Partnership, a collaboration of five nonprofit health plans covering 4 million people, and physician groups representing some 5,000 primary care physicians.

In 2001, there were four pay-for-performance contracts in the state. That rose to 8 in 2002, and 18 in 2003.

Comparing Health Plan Employer Data and Information Set measures from the groups with those contracts to measures from control groups without contracts, Dr. Pearson found that, for 4 of 30 measures, the contract groups had more improvement for those years than the control groups. For 21 measures, the groups had similar improvement.

But, for five measures—chlamydia testing, hemoglobin A_1c testing in diabetics, LDL testing in diabetics, urine testing in diabetics, and well-child visits by adolescents—the control groups had more improvement. And, two of the four measures for which the contract groups outperformed the control groups were dominated by a special contract and a single 38-physician practice, Dr. Pearson said.

Moreover, when he restricted his analysis to just groups termed “high-incentive” groups, there was still no more improvement than controls. High-incentive groups were defined as ones that could receive performance bonuses of $100,000 or more, or for whom individual primary care physicians could receive bonuses of more than $1,000.

There are two plausible explanations for the findings, Dr. Pearson said. “Either P4P has worked in Massachusetts because it is part of this atmosphere of driving quality improvement … or P4P has failed because it is either too weak—not enough money on the table—or it was poorly designed.”

Money indeed may turn out to be the pressing issue as pay for performance becomes more common.

Slowly but surely, many physicians seem to be coming around to pay for performance because they see it as an effort in medicine to make quality a priority, these investigators said.

But Dr. Damberg said California groups have told her they want to “see more skin in the game” to help them recoup the investments they have had to make to adapt to the programs. If it doesn't come, she is afraid they will lose patience.

“It is really still too early to declare victory or defeat for pay for performance,” Dr. Damberg concluded. “These programs take a while to stabilize.

“It's really important to look at these over a much longer time frame because people move through different stages of engagement, denial, or whatever label you want to put on it,” she added.

Fragmented Care Creates a Problem for Pay-for-Performance Plans, Study Says

Pay-for-performance schemes may be thwarted by patients seeing too many doctors, making it difficult to assign any one patient's care to a particular physician, according to a study presented at the annual research meeting of AcademyHealth.

The average Medicare patient sees seven physicians (two primary care, five specialists) over a 2-year period, Dr. Hoangmai Pham, a senior researcher with the Center for Studying Health System Change, Washington, said at the meeting.

Dr. Pham analyzed data from a number of Medicare sources to come to her conclusion. These sources included claims data and nationwide physician surveys for 2000–2003.

Not only do patients see a number of physicians, but their main physician may not even see them the majority of the time; they also switch their primary provider often.

Only 53% of Medicare beneficiaries' evaluation and management visits, and 35% of their total visits, are with the physician identified as their primary, or usual-source-of-care, physician.

During a 2-year period, 30% of beneficiaries switch their usual-source-of-care physician, and in 59% of the cases where beneficiaries switch, they never even see one of the designated physicians in a year, Dr. Pham said.

According to the physician survey data, a primary care physician's regular, usual-source-of-care patients make up an average of only 39% of his or her total patient population.

These figures show that in today's medical environment, it takes more than one doctor to care for a patient, Dr. Pham said.

The Department of Health and Human Services has committed the Medicare program to advancing the concept of pay for performance, Dr. Pham noted.

But what is really needed is an overhaul of the way the medical system is organized to allow single physicians or groups to actually be responsible for individual patients. Or, alternatively, there needs to be more financial incentive in pay for performance to make it worthwhile for physicians to invest in the infrastructure they need to participate, because they are going to be able to show good performance for only a small proportion of their patients, she added.

SEATTLE — When the physicians of Rochester, N.Y., first had a pay-for-performance program imposed on them, they ignored it.

“At the beginning of our program, most people would not acknowledge it existed,” said Dr. Howard B. Beckman, the medical director of the Rochester Individual Physician Association (IPA). “As we talked about the profiles, people said 'I never got them,' 'I threw them away,' or 'I don't care.'”

That denial ended when the first performance-based checks were disbursed, and after 3 years, pay-for-performance measures have paid off in reduced health plan costs of almost $5 million, Dr. Beckman said at the annual research meeting of AcademyHealth.

Dr. Beckman was one of three physicians who presented research on whether pay for performance improves quality of care and efficiency in medicine enough to make worthwhile all the effort being put into it.

He was the only one of the three to have a positive conclusion.

The other two investigations of pay for performance, in California and Massachusetts, looked more specifically at individual aspects of clinical care. Those investigators found they could not document an impact from the programs.

But those investigators also pointed out that, as in Rochester, it takes time for physicians to get accustomed to the idea of greater accountability, and to develop the capabilities to record and report for the programs, so their findings might reflect the fact that the programs have not been going long enough.

On the other hand, the findings may show that financial incentives do not work for professionals, something research in other fields has suggested, they noted.

The Rochester physicians went through stages of acceptance of pay for performance not unlike the stages of grief defined by Dr. Elisabeth Kübler-Ross, Dr. Beckman said.

After the first performance bonus checks were sent out and denial ended, there was anger. The physicians complained that strict performance measures impinge on their autonomy, and they were even offended by the implication that money could influence their behavior, he said.

Then, after about 2 years, the general resistance abated, and the angry phone calls stopped, Dr. Beckman said. Now when he gets phone calls about the program, it is an individual physician trying to negotiate something.

The Rochester IPA represents all 3,200 physicians in the Rochester area and has insurance contracts that cover about 50% of the community market. Its individual physician profiling program began in 2002.

The program's individual physician payments vary, but overall the program pays out about $15 million a year, and the average internist can earn from $4,000 to $12,000 from the quality reports. The physicians get three reports a year, and payments are made at the end of the year.

Dr. Beckman looked at the provider profile data for patients with diabetes and coronary artery disease. He found that when expected costs were compared with actual costs in the diabetes patients in 2003 and 2004, there was a savings of about $1 million in the first year and $2 million in the second year. Most of that savings, about $1.3 million, came from reduced inpatient hospitalization costs.

The savings for the coronary artery disease patients was about $2 million over the 2 years, for a total savings for just those two groups of patients of about $5 million, Dr. Beckman said. Given what the group had put into the program (about $1.1 million, mostly for computer capability), the return on investment for the program was about four times what was spent.

Dr. Beckman pointed out that many people have expressed concern that pay-for-performance programs could be unfair to physicians with the most difficult, least compliant patients, so he looked at different practices. It appeared that differences were greater between individual doctors than they were between practices and practice locations.

Pay for performance began in California at about the same time as the Rochester program, and it has yet to show any meaningful overall improvement in clinical care, said Cheryl L. Damberg, Ph.D., a researcher for the RAND Corp., who has been analyzing data from the California collaborative managed by the Integrated Healthcare Association, which includes seven HMOs and point-of-service plans contracting with 225 physician groups.

Surveys of patient satisfaction, a part of performance that is rewarded, showed gradual, substantive improvement in the first 2 years of the program. But when Dr. Damberg looked at clinical care measures, such as aspects of diabetes care, Pap smears, and childhood immunization, any improvement seen between years is inconsistent and varied.

She concluded, based on an analysis of the patterns of improvement, that many physicians and groups are getting up to speed with reporting, so it is too early to judge the impact on actual clinical care.

“Some areas have seen more dramatic improvement than others,” she added. But “this is not the dramatic breakthrough we are all looking for to close the quality chasms.”

In Massachusetts, doctors with pay-for-performance contracts have improved their quality since programs were introduced into the state, but so have doctors without contracts, said Dr. Steven D. Pearson, the director of the Center for Ethics in Managed Care at Harvard Medical School, Boston.

He looked at data collected from the state's pay-for-performance programs put together by the Massachusetts Health Quality Partnership, a collaboration of five nonprofit health plans covering 4 million people, and physician groups representing some 5,000 primary care physicians.

In 2001, there were four pay-for-performance contracts in the state. That rose to 8 in 2002, and 18 in 2003.

Comparing Health Plan Employer Data and Information Set measures from the groups with those contracts to measures from control groups without contracts, Dr. Pearson found that, for 4 of 30 measures, the contract groups had more improvement for those years than the control groups. For 21 measures, the groups had similar improvement.

But, for five measures—chlamydia testing, hemoglobin A_1c testing in diabetics, LDL testing in diabetics, urine testing in diabetics, and well-child visits by adolescents—the control groups had more improvement.

And, two of the four measures for which the contract groups outperformed the control groups were dominated by a special contract and a single 38-physician practice, Dr. Pearson said.

Moreover, when he restricted his analysis to just groups termed “high-incentive” groups, there was still no more improvement than controls. High-incentive groups were defined as ones that could receive performance bonuses of $100,000 or more, or for whom individual primary care physicians could receive bonuses of more than $1,000.

There are two plausible explanations for the findings, Dr. Pearson said. “Either P4P has worked in Massachusetts because it is part of this atmosphere of driving quality improvement … or P4P has failed because it is either too weak—not enough money on the table—or it was poorly designed.”

Money indeed may turn out to be the pressing issue as pay for performance becomes more common.

Slowly but surely, many physicians seem to be coming around to pay for performance because they see it as an effort in medicine to make quality a priority, these investigators said.

But Dr. Damberg said California groups have told her they want to “see more skin in the game” to help them recoup the investments they have had to make to adapt to the programs. If it doesn't come, she is afraid they will lose patience.

“It is really still too early to declare victory or defeat for pay for performance,” Dr. Damberg concluded. “These programs take a while to stabilize.

“It's really important to look at these over a much longer time frame because people move through different stages of engagement, denial, or whatever label you want to put on it,” she added.

Fragmented Care Poses Challenges

Pay-for-performance schemes may be thwarted by patients seeing too many doctors, making it difficult to assign any one patient's care to a particular physician, according to a study presented at the annual research meeting of AcademyHealth.

The average Medicare patient sees seven physicians (two primary care, five specialists) over a 2-year period, Dr. Hoangmai Pham, a senior researcher with the Center for Studying Health System Change, Washington, said at the meeting.

Dr. Pham analyzed data from a number of Medicare sources to come to her conclusion. These sources included claims data and nationwide physician surveys for 2000–2003.

Not only do patients see a number of physicians, but their main physician may not even see them the majority of the time; they also switch their primary provider often.

Only 53% of Medicare beneficiaries' evaluation and management visits, and 35% of their total visits, are with the physician identified as their primary, or usual-source-of-care, physician.

During a 2-year period, 30% of beneficiaries switch their usual-source-of-care physician, and in 59% of the cases where beneficiaries switch, they never even see one of the designated physicians in a year, Dr. Pham said.

According to the physician survey data, a primary care physician's regular, usual-source-of-care patients make up an average of only 39% of his or her total patient population.

These figures show that in today's medical environment, it takes more than one doctor to care for a patient, Dr. Pham said.

The Department of Health and Human Services has committed the Medicare program to advancing the concept of pay for performance, Dr. Pham noted.

But what is really needed is an overhaul of the way the medical system is organized to allow single physicians or groups to actually be responsible for individual patients. Or, alternatively, there needs to be more financial incentive in pay for performance to make it worthwhile for physicians to invest in the infrastructure they need to participate, because they are going to be able to show good performance for only a small proportion of their patients, she added.

SEATTLE — When the physicians of Rochester, N.Y., first had a pay-for-performance program imposed on them, they ignored it.

“At the beginning of our program, most people would not acknowledge it existed,” said Dr. Howard B. Beckman, the medical director of the Rochester Individual Physician Association (IPA). “As we talked about the profiles, people said 'I never got them,' 'I threw them away,' or 'I don't care.'”

That denial ended when the first performance-based checks were disbursed, and after 3 years, pay-for-performance measures have paid off in reduced health plan costs of almost $5 million, Dr. Beckman said at the annual research meeting of AcademyHealth.

Dr. Beckman was one of three physicians who presented research on whether pay for performance improves quality of care and efficiency in medicine enough to make worthwhile all the effort being put into it.

He was the only one of the three to have a positive conclusion.

The other two investigations of pay for performance, in California and Massachusetts, looked more specifically at individual aspects of clinical care. Those investigators found they could not document an impact from the programs.

But those investigators also pointed out that, as in Rochester, it takes time for physicians to get accustomed to the idea of greater accountability, and to develop the capabilities to record and report for the programs, so their findings might reflect the fact that the programs have not been going long enough.

On the other hand, the findings may show that financial incentives do not work for professionals, something research in other fields has suggested, they noted.

The Rochester physicians went through stages of acceptance of pay for performance not unlike the stages of grief defined by Dr. Elisabeth Kübler-Ross, Dr. Beckman said.

After the first performance bonus checks were sent out and denial ended, there was anger. The physicians complained that strict performance measures impinge on their autonomy, and they were even offended by the implication that money could influence their behavior, he said.

Then, after about 2 years, the general resistance abated, and the angry phone calls stopped, Dr. Beckman said. Now when he gets phone calls about the program, it is an individual physician trying to negotiate something.

The Rochester IPA represents all 3,200 physicians in the Rochester area and has insurance contracts that cover about 50% of the community market. Its individual physician profiling program began in 2002.

The program's individual physician payments vary, but overall the program pays out about $15 million a year, and the average internist can earn from $4,000 to $12,000 from the quality reports. The physicians get three reports a year, and payments are made at the end of the year.

Dr. Beckman looked at the provider profile data for patients with diabetes and coronary artery disease. He found that when expected costs were compared with actual costs in the diabetes patients in 2003 and 2004, there was a savings of about $1 million in the first year and $2 million in the second year. Most of that savings, about $1.3 million, came from reduced inpatient hospitalization costs.

The savings for the coronary artery disease patients was about $2 million over the 2 years, for a total savings for just those two groups of patients of about $5 million, Dr. Beckman said. Given what the group had put into the program (about $1.1 million, mostly for computer capability), the return on investment for the program was about four times what was spent.

Dr. Beckman pointed out that many people have expressed concern that pay-for-performance programs could be unfair to physicians with the most difficult, least compliant patients, so he looked at different practices. It appeared that differences were greater between individual doctors than they were between practices and practice locations.

Pay for performance began in California at about the same time as the Rochester program, and it has yet to show any meaningful overall improvement in clinical care, said Cheryl L. Damberg, Ph.D., a researcher for the RAND Corp., who has been analyzing data from the California collaborative managed by the Integrated Healthcare Association, which includes seven HMOs and point-of-service plans contracting with 225 physician groups.

Surveys of patient satisfaction, a part of performance that is rewarded, showed gradual, substantive improvement in the first 2 years of the program. But when Dr. Damberg looked at clinical care measures, such as aspects of diabetes care, Pap smears, and childhood immunization, any improvement seen between years is inconsistent and varied.

She concluded, based on an analysis of the patterns of improvement, that many physicians and groups are getting up to speed with reporting, so it is too early to judge the impact on actual clinical care.

“Some areas have seen more dramatic improvement than others,” she added. But “this is not the dramatic breakthrough we are all looking for to close the quality chasms.”

In Massachusetts, doctors with pay-for-performance contracts have improved their quality since programs were introduced into the state, but so have doctors without contracts, said Dr. Steven D. Pearson, the director of the Center for Ethics in Managed Care at Harvard Medical School, Boston.

He looked at data collected from the state's pay-for-performance programs put together by the Massachusetts Health Quality Partnership, a collaboration of five nonprofit health plans covering 4 million people, and physician groups representing some 5,000 primary care physicians.

In 2001, there were four pay-for-performance contracts in the state. That rose to 8 in 2002, and 18 in 2003.

Comparing Health Plan Employer Data and Information Set measures from the groups with those contracts to measures from control groups without contracts, Dr. Pearson found that, for 4 of 30 measures, the contract groups had more improvement for those years than the control groups. For 21 measures, the groups had similar improvement.

But, for five measures—chlamydia testing, hemoglobin A_1c testing in diabetics, LDL testing in diabetics, urine testing in diabetics, and well-child visits by adolescents—the control groups had more improvement.

And, two of the four measures for which the contract groups outperformed the control groups were dominated by a special contract and a single 38-physician practice, Dr. Pearson said.

Moreover, when he restricted his analysis to just groups termed “high-incentive” groups, there was still no more improvement than controls. High-incentive groups were defined as ones that could receive performance bonuses of $100,000 or more, or for whom individual primary care physicians could receive bonuses of more than $1,000.

There are two plausible explanations for the findings, Dr. Pearson said. “Either P4P has worked in Massachusetts because it is part of this atmosphere of driving quality improvement … or P4P has failed because it is either too weak—not enough money on the table—or it was poorly designed.”

Money indeed may turn out to be the pressing issue as pay for performance becomes more common.

Slowly but surely, many physicians seem to be coming around to pay for performance because they see it as an effort in medicine to make quality a priority, these investigators said.

But Dr. Damberg said California groups have told her they want to “see more skin in the game” to help them recoup the investments they have had to make to adapt to the programs. If it doesn't come, she is afraid they will lose patience.

“It is really still too early to declare victory or defeat for pay for performance,” Dr. Damberg concluded. “These programs take a while to stabilize.

“It's really important to look at these over a much longer time frame because people move through different stages of engagement, denial, or whatever label you want to put on it,” she added.

Fragmented Care Poses Challenges

Pay-for-performance schemes may be thwarted by patients seeing too many doctors, making it difficult to assign any one patient's care to a particular physician, according to a study presented at the annual research meeting of AcademyHealth.

The average Medicare patient sees seven physicians (two primary care, five specialists) over a 2-year period, Dr. Hoangmai Pham, a senior researcher with the Center for Studying Health System Change, Washington, said at the meeting.

Dr. Pham analyzed data from a number of Medicare sources to come to her conclusion. These sources included claims data and nationwide physician surveys for 2000–2003.

Not only do patients see a number of physicians, but their main physician may not even see them the majority of the time; they also switch their primary provider often.

Only 53% of Medicare beneficiaries' evaluation and management visits, and 35% of their total visits, are with the physician identified as their primary, or usual-source-of-care, physician.

During a 2-year period, 30% of beneficiaries switch their usual-source-of-care physician, and in 59% of the cases where beneficiaries switch, they never even see one of the designated physicians in a year, Dr. Pham said.

According to the physician survey data, a primary care physician's regular, usual-source-of-care patients make up an average of only 39% of his or her total patient population.

These figures show that in today's medical environment, it takes more than one doctor to care for a patient, Dr. Pham said.

The Department of Health and Human Services has committed the Medicare program to advancing the concept of pay for performance, Dr. Pham noted.

But what is really needed is an overhaul of the way the medical system is organized to allow single physicians or groups to actually be responsible for individual patients. Or, alternatively, there needs to be more financial incentive in pay for performance to make it worthwhile for physicians to invest in the infrastructure they need to participate, because they are going to be able to show good performance for only a small proportion of their patients, she added.

SEATTLE — When the physicians of Rochester, N.Y., first had a pay-for-performance program imposed on them, they ignored it.

“At the beginning of our program, most people would not acknowledge it existed,” said Dr. Howard B. Beckman, the medical director of the Rochester Individual Physician Association (IPA). “As we talked about the profiles, people said 'I never got them,' 'I threw them away,' or 'I don't care.'”

That denial ended when the first performance-based checks were disbursed, and after 3 years, pay-for-performance measures have paid off in reduced health plan costs of almost $5 million, Dr. Beckman said at the annual research meeting of AcademyHealth.

Dr. Beckman was one of three physicians who presented research on whether pay for performance improves quality of care and efficiency in medicine enough to make worthwhile all the effort being put into it.

He was the only one of the three to have a positive conclusion.

The other two investigations of pay for performance, in California and Massachusetts, looked more specifically at individual aspects of clinical care. Those investigators found they could not document an impact from the programs.

But those investigators also pointed out that, as in Rochester, it takes time for physicians to get accustomed to the idea of greater accountability, and to develop the capabilities to record and report for the programs, so their findings might reflect the fact that the programs have not been going long enough.

On the other hand, the findings may show that financial incentives do not work for professionals, something research in other fields has suggested, they noted.

The Rochester physicians went through stages of acceptance of pay for performance not unlike the stages of grief defined by Dr. Elisabeth Kübler-Ross, Dr. Beckman said.

After the first performance bonus checks were sent out and denial ended, there was anger. The physicians complained that strict performance measures impinge on their autonomy, and they were even offended by the implication that money could influence their behavior, he said.

Then, after about 2 years, the general resistance abated, and the angry phone calls stopped, Dr. Beckman said. Now when he gets phone calls about the program, it is an individual physician trying to negotiate something.

The Rochester IPA represents all 3,200 physicians in the Rochester area and has insurance contracts that cover about 50% of the community market. Its individual physician profiling program began in 2002.

The program's individual physician payments vary, but overall the program pays out about $15 million a year, and the average internist can earn from $4,000 to $12,000 from the quality reports. The physicians get three reports a year, and payments are made at the end of the year.

Dr. Beckman looked at the provider profile data for patients with diabetes and coronary artery disease. He found that when expected costs were compared with actual costs in the diabetes patients in 2003 and 2004, there was a savings of about $1 million in the first year and $2 million in the second year. Most of that savings, about $1.3 million, came from reduced inpatient hospitalization costs.

The savings for the coronary artery disease patients was about $2 million over the 2 years, for a total savings for just those two groups of patients of about $5 million, Dr. Beckman said. Given what the group had put into the program (about $1.1 million, mostly for computer capability), the return on investment for the program was about four times what was spent.

Dr. Beckman pointed out that many people have expressed concern that pay-for-performance programs could be unfair to physicians with the most difficult, least compliant patients, so he looked at different practices. It appeared that differences were greater between individual doctors than they were between practices and practice locations.

Pay for performance began in California at about the same time as the Rochester program, and it has yet to show any meaningful overall improvement in clinical care, said Cheryl L. Damberg, Ph.D., a researcher for the RAND Corp., who has been analyzing data from the California collaborative managed by the Integrated Healthcare Association, which includes seven HMOs and point-of-service plans contracting with 225 physician groups.

Surveys of patient satisfaction, a part of performance that is rewarded, showed gradual, substantive improvement in the first 2 years of the program. But when Dr. Damberg looked at clinical care measures, such as aspects of diabetes care, Pap smears, and childhood immunization, any improvement seen between years is inconsistent and varied.

She concluded, based on an analysis of the patterns of improvement, that many physicians and groups are getting up to speed with reporting, so it is too early to judge the impact on actual clinical care.

“Some areas have seen more dramatic improvement than others,” she added. But “this is not the dramatic breakthrough we are all looking for to close the quality chasms.”

In Massachusetts, doctors with pay-for-performance contracts have improved their quality since programs were introduced into the state, but so have doctors without contracts, said Dr. Steven D. Pearson, the director of the Center for Ethics in Managed Care at Harvard Medical School, Boston.

He looked at data collected from the state's pay-for-performance programs put together by the Massachusetts Health Quality Partnership, a collaboration of five nonprofit health plans covering 4 million people, and physician groups representing some 5,000 primary care physicians.

In 2001, there were four pay-for-performance contracts in the state. That rose to 8 in 2002, and 18 in 2003.

Comparing Health Plan Employer Data and Information Set measures from the groups with those contracts to measures from control groups without contracts, Dr. Pearson found that, for 4 of 30 measures, the contract groups had more improvement for those years than the control groups. For 21 measures, the groups had similar improvement.

But, for five measures—chlamydia testing, hemoglobin A_1c testing in diabetics, LDL testing in diabetics, urine testing in diabetics, and well-child visits by adolescents—the control groups had more improvement.

And, two of the four measures for which the contract groups outperformed the control groups were dominated by a special contract and a single 38-physician practice, Dr. Pearson said.

Moreover, when he restricted his analysis to just groups termed “high-incentive” groups, there was still no more improvement than controls. High-incentive groups were defined as ones that could receive performance bonuses of $100,000 or more, or for whom individual primary care physicians could receive bonuses of more than $1,000.

There are two plausible explanations for the findings, Dr. Pearson said. “Either P4P has worked in Massachusetts because it is part of this atmosphere of driving quality improvement … or P4P has failed because it is either too weak—not enough money on the table—or it was poorly designed.”

Money indeed may turn out to be the pressing issue as pay for performance becomes more common.

Slowly but surely, many physicians seem to be coming around to pay for performance because they see it as an effort in medicine to make quality a priority, these investigators said.

But Dr. Damberg said California groups have told her they want to “see more skin in the game” to help them recoup the investments they have had to make to adapt to the programs. If it doesn't come, she is afraid they will lose patience.

“It is really still too early to declare victory or defeat for pay for performance,” Dr. Damberg concluded. “These programs take a while to stabilize.

“It's really important to look at these over a much longer time frame because people move through different stages of engagement, denial, or whatever label you want to put on it,” she added.

Fragmented Care Poses Challenges

Pay-for-performance schemes may be thwarted by patients seeing too many doctors, making it difficult to assign any one patient's care to a particular physician, according to a study presented at the annual research meeting of AcademyHealth.

The average Medicare patient sees seven physicians (two primary care, five specialists) over a 2-year period, Dr. Hoangmai Pham, a senior researcher with the Center for Studying Health System Change, Washington, said at the meeting.

Dr. Pham analyzed data from a number of Medicare sources to come to her conclusion. These sources included claims data and nationwide physician surveys for 2000–2003.

Not only do patients see a number of physicians, but their main physician may not even see them the majority of the time; they also switch their primary provider often.

Only 53% of Medicare beneficiaries' evaluation and management visits, and 35% of their total visits, are with the physician identified as their primary, or usual-source-of-care, physician.

During a 2-year period, 30% of beneficiaries switch their usual-source-of-care physician, and in 59% of the cases where beneficiaries switch, they never even see one of the designated physicians in a year, Dr. Pham said.

According to the physician survey data, a primary care physician's regular, usual-source-of-care patients make up an average of only 39% of his or her total patient population.

These figures show that in today's medical environment, it takes more than one doctor to care for a patient, Dr. Pham said.

The Department of Health and Human Services has committed the Medicare program to advancing the concept of pay for performance, Dr. Pham noted.

But what is really needed is an overhaul of the way the medical system is organized to allow single physicians or groups to actually be responsible for individual patients. Or, alternatively, there needs to be more financial incentive in pay for performance to make it worthwhile for physicians to invest in the infrastructure they need to participate, because they are going to be able to show good performance for only a small proportion of their patients, she added.

SEATTLE — Elderly persons who undergo major bowel operations on an elective basis fare much better than those who have emergency surgery, Dr. Demetrios J. Louis said at the annual meeting of the American Society of Colon and Rectal Surgeons.

Dr. Louis reviewed 138 patients over the age of 80 years who underwent major intestinal operations at Rush University Medical Center, Chicago, between 1995 and 2005. Overall, 53% of the 138 patients had surgical complications and the mortality rate was 8%. He found much higher rates of complications, morbidity, and mortality in those who had the emergent procedures than in those who had elective procedures. For instance, their length of hospital stay was 2.7 times longer (21 days average versus 8 days), their major complication rate was more than twice as high (81% versus 35%), and their mortality rate was more than 16 times higher (32% versus 2%).

Patients who underwent emergency procedures tended to have significantly worse American Society of Anesthesiologists (ASA) status.

The findings suggest that success in older individuals is determined primarily by ASA status and the need for emergency surgery and, therefore, that “absolute age is not a determinant in outcome,” said Dr. Louis, of the department of general surgery at Rush University.

SEATTLE — Elderly persons who undergo major bowel operations on an elective basis fare much better than those who have emergency surgery, Dr. Demetrios J. Louis said at the annual meeting of the American Society of Colon and Rectal Surgeons.

Dr. Louis reviewed 138 patients over the age of 80 years who underwent major intestinal operations at Rush University Medical Center, Chicago, between 1995 and 2005. Overall, 53% of the 138 patients had surgical complications and the mortality rate was 8%. He found much higher rates of complications, morbidity, and mortality in those who had the emergent procedures than in those who had elective procedures. For instance, their length of hospital stay was 2.7 times longer (21 days average versus 8 days), their major complication rate was more than twice as high (81% versus 35%), and their mortality rate was more than 16 times higher (32% versus 2%).

Patients who underwent emergency procedures tended to have significantly worse American Society of Anesthesiologists (ASA) status.

The findings suggest that success in older individuals is determined primarily by ASA status and the need for emergency surgery and, therefore, that “absolute age is not a determinant in outcome,” said Dr. Louis, of the department of general surgery at Rush University.

SEATTLE — Elderly persons who undergo major bowel operations on an elective basis fare much better than those who have emergency surgery, Dr. Demetrios J. Louis said at the annual meeting of the American Society of Colon and Rectal Surgeons.

Dr. Louis reviewed 138 patients over the age of 80 years who underwent major intestinal operations at Rush University Medical Center, Chicago, between 1995 and 2005. Overall, 53% of the 138 patients had surgical complications and the mortality rate was 8%. He found much higher rates of complications, morbidity, and mortality in those who had the emergent procedures than in those who had elective procedures. For instance, their length of hospital stay was 2.7 times longer (21 days average versus 8 days), their major complication rate was more than twice as high (81% versus 35%), and their mortality rate was more than 16 times higher (32% versus 2%).

Patients who underwent emergency procedures tended to have significantly worse American Society of Anesthesiologists (ASA) status.

The findings suggest that success in older individuals is determined primarily by ASA status and the need for emergency surgery and, therefore, that “absolute age is not a determinant in outcome,” said Dr. Louis, of the department of general surgery at Rush University.

SEATTLE — Nearly half of a sample of elderly persons in Los Angeles were taking medications that they probably should not have been, and the likelihood of such a problem rose sharply with the number of medications they were taking, Gretchen E. Alkema said at the annual research meeting of AcademyHealth.

In fact, of the elderly persons who were taking 12 or more medications, 70% had one or more medication problems, and of those taking 7–9 medications, 50% had one or more medication problems.

About one-half of the individuals who participated in the study were taking nine or more medications.

The study shows how complicated caring for the elderly has become and how frequently they end up being given a medication they shouldn't be using, said Ms. Alkema of the Davis School of Gerontology at the University of Southern California, Los Angeles, in a poster presentation.

The study looked at a cohort of 615 individuals in a Medicaid waiver program who were living at home but were at risk for institutionalization. Their average age was 80 years, about 40% were living alone, and 60% were English speaking.

A pharmacist reviewed each individual's medications by using a validated home-health screening tool, looking for four types of medication problems:

▸ Unnecessary therapeutic duplication.

▸ Inappropriate psychotropic medication use in a person with confusion or a fall in the past 3 months.

▸ Cardiovascular medication problems, such as poorly controlled hypertension based on dizziness, blood pressure, or pulse.

▸ Inappropriate NSAID use in a patient at risk for peptic ulcer complications (over age 80 years, on an anticoagulant, or on a corticosteroid).

Overall, 49% had one medication problem, 19% had two medication problems, and 5% had three or more problems. The most common type of problem was therapeutic duplication, in 24% of the individuals, followed by inappropriate psychotropic use and cardiovascular medication problems, each in 14% of the individuals, and finally, inappropriate NSAID use, in 13% of the individuals.

Apart from simply the number of medications a person was using, the study found that an important risk factor associated with medication error was that the individual had been to a hospital, emergency department, or skilled nursing facility in the past year. Those contacts with the medical system doubled the risk of a problem.

SEATTLE — Nearly half of a sample of elderly persons in Los Angeles were taking medications that they probably should not have been, and the likelihood of such a problem rose sharply with the number of medications they were taking, Gretchen E. Alkema said at the annual research meeting of AcademyHealth.

In fact, of the elderly persons who were taking 12 or more medications, 70% had one or more medication problems, and of those taking 7–9 medications, 50% had one or more medication problems.

About one-half of the individuals who participated in the study were taking nine or more medications.

The study shows how complicated caring for the elderly has become and how frequently they end up being given a medication they shouldn't be using, said Ms. Alkema of the Davis School of Gerontology at the University of Southern California, Los Angeles, in a poster presentation.

The study looked at a cohort of 615 individuals in a Medicaid waiver program who were living at home but were at risk for institutionalization. Their average age was 80 years, about 40% were living alone, and 60% were English speaking.

A pharmacist reviewed each individual's medications by using a validated home-health screening tool, looking for four types of medication problems:

▸ Unnecessary therapeutic duplication.

▸ Inappropriate psychotropic medication use in a person with confusion or a fall in the past 3 months.

▸ Cardiovascular medication problems, such as poorly controlled hypertension based on dizziness, blood pressure, or pulse.

▸ Inappropriate NSAID use in a patient at risk for peptic ulcer complications (over age 80 years, on an anticoagulant, or on a corticosteroid).

Overall, 49% had one medication problem, 19% had two medication problems, and 5% had three or more problems. The most common type of problem was therapeutic duplication, in 24% of the individuals, followed by inappropriate psychotropic use and cardiovascular medication problems, each in 14% of the individuals, and finally, inappropriate NSAID use, in 13% of the individuals.

Apart from simply the number of medications a person was using, the study found that an important risk factor associated with medication error was that the individual had been to a hospital, emergency department, or skilled nursing facility in the past year. Those contacts with the medical system doubled the risk of a problem.

SEATTLE — Nearly half of a sample of elderly persons in Los Angeles were taking medications that they probably should not have been, and the likelihood of such a problem rose sharply with the number of medications they were taking, Gretchen E. Alkema said at the annual research meeting of AcademyHealth.

In fact, of the elderly persons who were taking 12 or more medications, 70% had one or more medication problems, and of those taking 7–9 medications, 50% had one or more medication problems.

About one-half of the individuals who participated in the study were taking nine or more medications.

The study shows how complicated caring for the elderly has become and how frequently they end up being given a medication they shouldn't be using, said Ms. Alkema of the Davis School of Gerontology at the University of Southern California, Los Angeles, in a poster presentation.

The study looked at a cohort of 615 individuals in a Medicaid waiver program who were living at home but were at risk for institutionalization. Their average age was 80 years, about 40% were living alone, and 60% were English speaking.

A pharmacist reviewed each individual's medications by using a validated home-health screening tool, looking for four types of medication problems:

▸ Unnecessary therapeutic duplication.

▸ Inappropriate psychotropic medication use in a person with confusion or a fall in the past 3 months.

▸ Cardiovascular medication problems, such as poorly controlled hypertension based on dizziness, blood pressure, or pulse.

▸ Inappropriate NSAID use in a patient at risk for peptic ulcer complications (over age 80 years, on an anticoagulant, or on a corticosteroid).

Overall, 49% had one medication problem, 19% had two medication problems, and 5% had three or more problems. The most common type of problem was therapeutic duplication, in 24% of the individuals, followed by inappropriate psychotropic use and cardiovascular medication problems, each in 14% of the individuals, and finally, inappropriate NSAID use, in 13% of the individuals.

Apart from simply the number of medications a person was using, the study found that an important risk factor associated with medication error was that the individual had been to a hospital, emergency department, or skilled nursing facility in the past year. Those contacts with the medical system doubled the risk of a problem.

SEATTLE – The rate of opioid use varies considerably from state to state, with some of the highest rates found in Indiana and Maine, and the lowest in California and Minnesota, federal prescription claims data show.

That variation is inexplicable medically, and suggests that either opioids are being used too liberally in some states, not enough in others, or both, Dr. Judy T. Zerzan said in a poster presentation at the annual research meeting of Academy Health.

Medicare and Medicaid prescribing figures from the start of 1996 to the end of 2002 show that nationwide, the increase in prescribing of opioids since the middle of the 1990s was great. Furthermore, that increase coincides with efforts aimed at improving the treatment of pain, noted Dr. Zerzan of the division of general internal medicine at the University of Washington, Seattle.

Over the 7 years of the study, opioid prescribing nationally increased a mean of 24% per year. That figure compares with a mean annual increase of just 12% for an index known as the “market basket” that is used to measure general prescribing, according to the figures.

But the increase in opioid prescribing has not been exactly uniform. For example, only two-thirds of the states had an increase in the prescribing of opioids. And some had a greater relative increase than others, Dr. Zerzan said.

Moreover, her study found that 10 states had prescribing at the rate of 87–200 defined daily doses per 1,000 Medicaid beneficiaries per day in 2002, while 8 states had prescribing at a rate of 0–39 defined daily doses per 1,000 Medicaid beneficiaries per day. The rest had rates that fell in between the two.

“Defined daily dose” is a construct developed by the World Health Organization that states a standardized dose rate for different drugs.

The 10 states with the highest rate were Alaska, Indiana, Louisiana, Maine, Maryland, Missouri, Mississippi, Montana, North Carolina, and West Virginia. The eight states with the lowest rate were California, Minnesota, New Jersey, New Mexico, New York, Pennsylvania, Tennessee, and Vermont.

Among the possible explanations for the variation in use are differing state prescription benefit policies, marketing of the drugs has been different in different regions, and physician attitudes toward opioids vary by region, Dr. Zerzan said.

SEATTLE – The rate of opioid use varies considerably from state to state, with some of the highest rates found in Indiana and Maine, and the lowest in California and Minnesota, federal prescription claims data show.

That variation is inexplicable medically, and suggests that either opioids are being used too liberally in some states, not enough in others, or both, Dr. Judy T. Zerzan said in a poster presentation at the annual research meeting of Academy Health.

Medicare and Medicaid prescribing figures from the start of 1996 to the end of 2002 show that nationwide, the increase in prescribing of opioids since the middle of the 1990s was great. Furthermore, that increase coincides with efforts aimed at improving the treatment of pain, noted Dr. Zerzan of the division of general internal medicine at the University of Washington, Seattle.

Over the 7 years of the study, opioid prescribing nationally increased a mean of 24% per year. That figure compares with a mean annual increase of just 12% for an index known as the “market basket” that is used to measure general prescribing, according to the figures.

But the increase in opioid prescribing has not been exactly uniform. For example, only two-thirds of the states had an increase in the prescribing of opioids. And some had a greater relative increase than others, Dr. Zerzan said.

Moreover, her study found that 10 states had prescribing at the rate of 87–200 defined daily doses per 1,000 Medicaid beneficiaries per day in 2002, while 8 states had prescribing at a rate of 0–39 defined daily doses per 1,000 Medicaid beneficiaries per day. The rest had rates that fell in between the two.

“Defined daily dose” is a construct developed by the World Health Organization that states a standardized dose rate for different drugs.

The 10 states with the highest rate were Alaska, Indiana, Louisiana, Maine, Maryland, Missouri, Mississippi, Montana, North Carolina, and West Virginia. The eight states with the lowest rate were California, Minnesota, New Jersey, New Mexico, New York, Pennsylvania, Tennessee, and Vermont.

Among the possible explanations for the variation in use are differing state prescription benefit policies, marketing of the drugs has been different in different regions, and physician attitudes toward opioids vary by region, Dr. Zerzan said.

SEATTLE – The rate of opioid use varies considerably from state to state, with some of the highest rates found in Indiana and Maine, and the lowest in California and Minnesota, federal prescription claims data show.

That variation is inexplicable medically, and suggests that either opioids are being used too liberally in some states, not enough in others, or both, Dr. Judy T. Zerzan said in a poster presentation at the annual research meeting of Academy Health.

Medicare and Medicaid prescribing figures from the start of 1996 to the end of 2002 show that nationwide, the increase in prescribing of opioids since the middle of the 1990s was great. Furthermore, that increase coincides with efforts aimed at improving the treatment of pain, noted Dr. Zerzan of the division of general internal medicine at the University of Washington, Seattle.

Over the 7 years of the study, opioid prescribing nationally increased a mean of 24% per year. That figure compares with a mean annual increase of just 12% for an index known as the “market basket” that is used to measure general prescribing, according to the figures.

But the increase in opioid prescribing has not been exactly uniform. For example, only two-thirds of the states had an increase in the prescribing of opioids. And some had a greater relative increase than others, Dr. Zerzan said.

Moreover, her study found that 10 states had prescribing at the rate of 87–200 defined daily doses per 1,000 Medicaid beneficiaries per day in 2002, while 8 states had prescribing at a rate of 0–39 defined daily doses per 1,000 Medicaid beneficiaries per day. The rest had rates that fell in between the two.

“Defined daily dose” is a construct developed by the World Health Organization that states a standardized dose rate for different drugs.

The 10 states with the highest rate were Alaska, Indiana, Louisiana, Maine, Maryland, Missouri, Mississippi, Montana, North Carolina, and West Virginia. The eight states with the lowest rate were California, Minnesota, New Jersey, New Mexico, New York, Pennsylvania, Tennessee, and Vermont.

Among the possible explanations for the variation in use are differing state prescription benefit policies, marketing of the drugs has been different in different regions, and physician attitudes toward opioids vary by region, Dr. Zerzan said.