Major health insurance companies claim to want more evidence of value for their large expenditures on healthcare. So they have promulgated pay for performance (P4P) programs throughout the healthcare industry.

In P4P programs, the measurement of biochemical markers glows as an indicator of quality healthcare. Physician groups count on rewards for excelling at measuring these biochemical markers. It seems the act of measuring quality is all the rage, but does it apply the same way in healthcare as it does in other industries, such as manufacturing?

The airplane manufacturing industry comes to mind as one example of intense quality control. Because jet aircraft must log thousands of safe flying hours, companies pay attention to markers of aircraft structural integrity. Microcomputers monitor all aspects of the aircraft to detect part failures. Audible alarms alert the flight crew to action when a problem is identified. Quality control engineers spend their careers looking for ways to improve parts and detect flaws.

No doubt the push to measure healthcare quality comes from the skepticism of major payers. But skeptical physicians are pushing back. Incredulously, they wonder, "They want us to measure biochemical markers as a measure of quality? Are people machines?"

Early on, I had that reaction, too, but have recently concluded that the payers are right. Our job is to measure the markers, detect problems early and avoid the "crash cart." P4P incentives do drive medical groups to develop systems needed to measure, monitor and correct patients' health. New detection markers demand that we make earlier interventions. True preventive medical care has arrived. Jump on the P4P train and enjoy the ride!

The End of the Line
What happens to the measurement of biochemical markers at the end of life? The benefits are less clear and come with heavy ethical implications.

To explain, I draw an analogy to the aircraft industry again. When an aircraft part wears to the point of danger, mechanics replace it. When too many parts require replacement, the company "retires" the aircraft. Quality engineers develop criteria for each scenario. At some point, the markers indicate the end of the aircraft's airworthiness. The aircraft becomes scrap metal.

Instances of replacing old parts in humans abound. Orthopedists, ophthalmologists and cardiac surgeons revel in new parts. Unfortunately, when the option of parts replacement fades, the quality of life ebbs. What end-of-life markers do we have? Flat EKGs or EEGs signal the final event. However, as we monitor disease states, will end-stage markers emerge to signal irreversible tissue destruction?

Many employers provide health insurance as a benefit. Maintaining a healthy work force once improved a company's competitive edge. Yet as rapid employee turnover became the norm, paying for insurance made less sense. So the 1990s brought a cost shift from employer to employee. And at retirement, the employee transfers his or her medical care burden to others in the form of Medicare.

Following the lead of major insurers, Medicare jumped on the P4P train. The Centers for Medicare and Medicaid Services want us to measure biological markers as an indicator of quality. CMS adopted the same criteria as the large payers. Young and middle-aged workers compared with aging seniors?

As we measure seniors for the markers of metabolic dysfunction and watch them slowly decline in spite of our interventions, when do we concede that we have lost control and accept reality that we cannot stop the aging process?

Medicare pays for the majority of end-of-life care. Much of the cost occurs in the final month of a person's life. Many describe this as "futile care." Will we develop early biologic markers signaling the end of life? Will Medicare establish criteria to monitor these markers? Can we ethically start the end-of-life care early? Will P4P assist in the decision? Will we jump on this train? Where is it going?

Lytton W. Smith, MD, editor for the OCMA, is a physician practicing family medicine with the St. Joseph Heritage Medical Group in Yorba Linda. Dr. Smith welcomes feedback on his articles and can be reached at ocmaeditor@ocdoc.com.