1. Implementing P4P in a Family Medicine Residency Program: From the Residents’ Point of View Laura Pattison MD Outgoing Chief and P4P Advocate Maya Miley MD Incoming Chief and P4P Skeptic

2. The Survey 1 strongly disagree 2 disagree3 neutral 4 agree 5 strongly agree 1. I feel I have a very good understanding of what “pay-for-performance” means. 2. I feel I have a very good understanding of P4P practice guidelines that our clinic is following at this time. 3. I believe P4P practice guidelines have improved my medical knowledge. 4. I believe P4P practice guidelines improve my efficiency in clinic. 5. In particular cases I have a conflict between doing the right thing clinically and following P4P guidelines. 6. I am insulted by the idea that I should follow practice guidelines for financial incentives. 7. I believe P4P will result in better patient outcomes. 8. I like the idea that physicians should be paid for quality of care as well as quantity of patients seen. 9. I like having clear goals and expectations for diabetes care (e.g. “grand slam”) 10. I believe P4P implementation at my clinic has improved my understanding of clinic operations/ finances. 11. I believe P4P practice guidelines are being smoothly integrated into practice at my residency program. 12. I find P4P practice guidelines to be distracting. 13. My overall impression of P4P is negative. 14. I believe I can fly. 15. I believe I can touch the sky. Comments:

3. I feel I have a very good understanding of what “pay for performance” means

4. I believe P4P practice guidelines have improved my medical knowledge

5. I believe that P4P practice guidelines improve my efficiency in clinic

6. In particular cases I have conflict between doing the right thing clinically and following P4P guidelines

7. I believe P4P will result in better patient outcomes

8. I like having clear goals and expectations for diabetes care

9. My overall impression of P4P is negative

10. I believe I can fly

11. I believe I can touch the sky

12. P4P and Medical Knowledge

13.  Cons Less critical thinking “tunnel vision” inability to see or manage well exceptions to the rules  Pros: Clear goals early on Faster learning Easy data collection for objective feed back

14. Physician-Patient relationship

15. P4P and Physician-Patient relationship  Pros:  Patient more engaged knowing the goals of their care  Enhances relationship appreciates aggressive and equal management  Cons Patient becoming a set of numbers v.s. humanistic vision Resentment towards patients not following our advice? Competing agendas

16. P4P and Patient Care

17.  Pros: More aggressive management to obtain excellent results Improves consistency Less errors or incomplete care? “Equality of care”  Cons: Guidelines not patient-population specific: medically complex, socially disadvantaged, elderly… Clinics serving these pts may be financially disadvantaged

18. P4P and Clinic Efficiency

19.  Pros: Clarity of guidelines allows consistent systematic approach to complicated diseases EMR templates can simplify a visit  Con: Increased documentation and bureaucracy

20. Conclusions  Overall response to P4P positive  Residents need more repeated exposure to general principals and specific guidelines of P4P  We need greater understanding of how this might impact medically and psychosocially complex patients