The principle behind pay for performance, P4P, is that certain performances, in terms of health services, are beneficial for the patient. P4P is a third party beneficiary relationship. The provider promises to provide, the payer promises to pay, and the patient receives a benefit. What happens when there is no benefit conferred? What happens when the rendered performance is for payment and has no good faith basis for benefitting the patient? P4P here must be pay faux performance.
From the picnic basket:
Eighteen year old male presents in the evening to an ER with complaint of substernal burning chest pain since early morning. Due to ER crowding, the patient is seen rapidly by the provider in the triage room and has serial ECGs and serial cardiac markers ordered while he remained in the waiting room. The patient remained in pain for three hours in the waiting room without any treatment until the ACS work-up was complete. He was then brought back to the same triage room and given a GI Cocktail with complete pain relief after 15 hours and discharged home.
Inspecting the picnic basket:
Reimbursement for the ER visit requires documentation of a thorough history, physical exam, and medical decision making that was the basis for the performance rendered. Big problem: the performance was fully rendered while the patient was waiting for an examination room. Chicken and egg? Cart and horse? Good faith? Eighteen year old male having an ACS work-up in the waiting room—how far can credibility be stretched? Who are the beneficiaries? Is this a faux performance paid for?
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