Iatrogenesis the adverse effects or complications caused by or resulting from medical treatment or advice. Fulminans the sudden or rapid onset of an intense phenomenon (often pain). P4P is all about the incentivization of “best practices” in healthcare, and in the race to meet P4P reimbursable–metrics the patient may be harmed.
Not long ago, a colleague asked me for help in treating a patient with congestive heart failure who had just been transferred from another hospital…the patient…was receiving an intravenous antibiotic every day. No one seemed to know why. Apparently it had been started in the emergency room at the other hospital because doctors there thought he might have pneumonia. But he did not appear to have pneumonia or any other infection. He had no fever. His white blood cell count was normal, and he wasn’t coughing up sputum. His chest X-ray did show a vague marking, but that was probably just fluid in the lungs from heart failure. I ordered the antibiotic stopped—but not in time to prevent the patient from developing a severe diarrheal infection called C. difficile colitis, often caused by antibiotics. He became dehydrated. His temperature spiked to alarming levels. His white blood cell count almost tripled. In the end, with different antibiotics, the infection was brought under control, but not before the patient had spent almost two weeks in the hospital.
Doctors have seldom been rewarded for excellence, at least not in any tangible way. In medical school, there were tests, board exams and lab practicals, but once you go into clinical practice, these traditional measures fall away. At first glance, pay for performance would seem to remedy this problem. But first its deep flaws must be addressed before patient care is compromised in unexpected ways.
P4P, a good idea perhaps, but when coupled with enhanced reimbursement is this “best practice” another example of faux performance? How often is non–existent pneumonia treated in the ER? And the much broader question, how often are non–existent conditions pursued and treated in healthcare? Should P4P–misadventures be the newest sentinel event? Should it be subject to never–event payment exclusions?
