‘Cookbook medicine’ debatable but has merit

In health care, "pay for performance" refers to the practice of payers and other health-field entities to encourage or require the performance or execution of certain prescribed tests or activities in the belief that they can attain better health care.

Examples of these guidelines are the requirements of insurance companies and payers such as Medicaid and Medicare that tests such as Hemoglobin A1c, blood glucose levels and eye examinations be required in the care of diabetics, and that blood pressures and antihypertensive medications be administered to patients with high blood pressure in order to be paid or reward-ed with a bonus.

Many physicians chafe under these requirements and refer to their adherence as "cookbook medicine." However, it should be said that the guidelines, or cookbook medicine, can be as useful to the average physician as a true cookbook is to the average cook.

No physician is beyond the need of reminders in the appropriate care of his or her patients.

Of equal importance, but less publicly understood, is the performance of tests and procedures considered of little value or even contraindicated.

In a recent article in the Journal of the American Medical Association (JAMA), 42 percent of 1.3 million Medicare patients received at least one unnecessary medical procedure in the study year, resulting in a wasting of $8 bil- lion.

This affects not only the quality of care, but also its cost.

It is significant in that the United States expends up to twice as much per capita on health care than other industrialized countries — but ranks between 15th and 30th among nations evaluated by the Organization for Economic Cooperation and Development in things such as infant mortality, communicable diseases, life expectancy, traumatic deaths and preventable cardiac deaths.

According to a Bloomberg ranking, the U.S. ranks 46th among 48 developed economies in health care efficiency. This is nothing for which to be boastful.

That being said, the devil is in the details.

In the presence of 184 associations and specialties that range from psychiatry to allergy, orthopedics, forensic pathology and dermatology to emergency medicine and so on almost ad infinitum, it is clear that codifying the requirements of good practice would be daunting.

For all stakeholders to agree on a manageable set of 10 or a dozen essential requirements applicable to patients ranging in age from the preterm fetus through childhood, adulthood and the aged would be at least difficult.

This does not mean that appropriate guidelines, i.e., the cookbook, cannot or should not be attempted. To this end, the July 2014 report of the Millbank Fund — titled "Advances in multi-payers alignment: State approaches to align performance metrics across public and private payers" — is instructive and should be perused.

Such information helps provide needed context in an evolving health care industry, and especially in light of a recent commentary by Dr. Stephen Kemble ("Health care pay-for-performance folly playing out," Star-Advertiser, Island Voices, July 9), who is immediate past president of the Hawaii Medical Association but whose column doesn’t constitute a position of either the HMA or the American Medical Association (AMA).

The diversity of HMA and AMA physician activities and interests makes it difficult for these memberships to consolidate a set of official guidelines — but the recognition of best practices is clearly afoot, and cannot be ignored.