Pay for Performance (P4P) and the Patient Centered Medical Home are two of the schemes being touted to save the nation from nefarious, inept and greedy doctors. Chief among arguments for these ideas are that more structured routine medical care will "increase quality" and "reduce health care costs". In essence, reward docs to do what 'someone' wants them to do (and imply future penalties if they don't).
An example of this approach is to reward (or not penalize) primary care doctors(PCP) for blood sugar and A1c "targets" achieved by their diabetic patients, typically A1c <7 and fasting CBGs <120. The PCP is rewarded or not based on the group performance of patients with the condition as though he/she is the only variable in the equation.
I have a middle-aged patient who elected to seek and receive surgical treatment for obesity in part because he had inadequate control of his diabetes (A1c 7.5-8) despite multiple medications, etc. He had no A1c (7.9) and CBG (~140 fasting) improvement after surgery, so the surgeon obtained a medicine/endocrine consultation(I was not involved). My patient is motivated and compliant with both medications and lifestyle choices.
The consultant recommended that my patient discontinue his diabetic medication as long as his fasting CBG stays below 180!
Now, if my patient chooses to follow the consultant's wisdom instead of my recommendation leading to worsened A1c and CBG numbers, should I be held financially responsible, as the PCP, for my patient's failure to meet the goal? Should my name go on the bad doctor list? Should I fire the patient?