As an addendum to yesterday's post, an article published in Health Affairs examines whether P4P might actually increase the disparity between the care received by the poor and the rich. This gap is not news, of course; the poor have historically been unable to afford proper care, and even now the only guarantee is that hospitals will not let you die. Even Medicaid doesn't really help when physicians refuse to see Medicaid patients due to low reimbursement rates.

The article cites five possible mechanisms: reduction in income for physicians in poor minority communities, culture-blind programs, "teaching to the test," physicians avoiding patients perceived as likely to lower quality scores, and patients' ability to use public quality reports. Obviously, a some of these mechanisms are linked, and some are more persuasive than others. For example, culture-blind programs, particularly those with materials written at a level (or in a language) that some find confusing, could easily lead to a perception that members of some groups are likely to lower quality scores, but I can't agree that a physician is any less likely to fail to explain a treatment regimen to an individual whose primary language is not English given the existence of a P4P program than would normally be the case. Further, I would argue a) that a properly-designed program takes into account clinical outcomes and so would not reward "teaching to the test" and b) that, in the case of a physician who was inclined to ignore such a large part of his or her job, providing the minimum recommended care in such a situation might be an improvement over the care he or she might usually provide.

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Related links - Terminology

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