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May 03, 2006


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Amy Tuteur

There's just one really significant problem: P4P is unethical. As I wrote on my own blog, Treat Me With Respect:

"The fundamental relationship in medicine is the doctor-patient relationship. Society and the law recognize this by privileging this relationship in comparison to other types of relationship. The doctor has a MORAL and and legal obligation to put the patient's interests and well-being above his own. Obviously, not every doctor will do that. There are some doctors who might recommend expensive treatments purely to enrich themselves. However, we understand those doctors to be unethical, and they may even be subject to legal action.

In dramatic contrast, however, P4P attempts to inject the insurer into the relationship. Even more objectionable, the insurer asks the doctor explicitly to balance the patient's interests against the doctor's financial interest. This is fundamentally unethical and should be banned as a result...

[T]he sanctity of the doctor patient relationship is a moral right. Insurers are not free to violate it simply because it may free up money to care for others (or more likely to profit the insurance company). Furthermore, it is UNETHICAL for an insurance company to ask doctors to violate this patient right.

Doctors should stand firm on this important point. We should refuse to participate in any system that is unethical on its face and we should aggressively charge the industry with their ethical violations."


The best and successful P4P programs will be the ones that put improved patient outcomes at the forefront. That is the second "P" -- performance!

Amy Tuteur


The problem is that performance is not based solely on patient outomes; it is based on "highest quality for lowest cost". These a big difference between those two forms of measurement.


Yes, there is a need for balance given limitations on resources! Patients and their advocates need to be heard on this issue to ensure proper balance and appropriate measures of performance and outcome.

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