Saturday, July 19, 2008

Pay-for-performance and physician professionalism

At Netroots Nation (bloggers’ conference, formerly YearlyKos) in Austin today, Lawrence Lessig addressed the crowd on problems of corruption, mostly focusing on government. Stipulating that vaccines do NOT cause autism and that they are good, he stated that National Vaccine Advisory Committee members are generally exempted from conflict of interest requirements and may make as much as $250,000 from the industry. He correlated this with a rise in parents' refusing vaccinations from 1% in 1991 to 2.5% in 2004. Whether or not money affects NVAC decisions, its presence (he insisted) erodes the basis of trust.

Pay-for-performance is the fashionable practice of the moment in bettering health care. But is it really a good idea?

It’s meant to address a real problem. Doctors and medical facilities are paid now for what they do, not for how well they do it or for how beneficial the care is. As a result, doctors and hospitals who provide only needed care or with sterling records in minimizing patient difficulties and complications are likely to find themselves in more financial difficulties than less careful and more average physicians and facilities. This problem is pressing – when good practice hurts the bottom line, it most certainly warps probity and professionalism .

The judgment of cardiac doctors, for example, has been distorted in our country by the fact that treating patients medically scarcely pays anything, while providing aggressive interventions is majorly lucrative. We are all human and more inclined to see benefit in something which benefits both us and a client.

However, the thesis that payers should instead reward good performance and pay bonuses to those who perform well, while sounding superficially fine, is actually fraught with problems. Providing doctors and hospitals substantial financial incentives to perform "according to specs" – like money provided to medical decision-makers and Congress by industry – will warp professionalism and patient trust.

  • The idea was introduced cleverly by saying Medicare and insurers should not pay for 'never events' – like amputating the wrong leg. Although I really have little or no problem with not paying for something so extreme, this was really a ‘nose under the tent’ approach. So-called 'never events' which won’t be paid for are quickly expanding to such things as post-op infections which yes, need to be minimized and reduced – but which also are sometimes going to occur.

  • Measuring outcomes is important, but tying remuneration to reported outcomes provides a built-in incentive for corruption. Hospitals are now going to be extremely concerned to diagnose as many conditions as possible in incoming patients lest they be penalized should something adverse occur later – and this will not likely always be objective. They also have incentives to reject less easy patients, when they can.

  • A complicated pay-for-performance remuneration system provides the need for physicians to take time and attention learning it and to "gaming the system." This is not the best use of physician time.

  • Pay-for-performance provides de facto disincentives to attending to needed care that does not generate bonuses. If a physician is rewarded for discussing obesity with patients, his attention may be to that rather than to noticing another problem that might be more important to his patient.

  • Physicians are concerned – and rightly – that pay-for-performance will hurt doctors who are willing to work with non-compliant patients – often among those who most need medical care. My niece in California (a leading pay-for-performance state at this time) already last year got a not-very-nice form letter from her doctor firing her and all other patients who were not up-to-date on mammograms and Pap smears.

  • Pay-for-performance is insulting to physicians. It assumes that they are only motivated to provide good medical care when money carrots are waved in front of them. The truth is, if we remove some of the agonies of medical practice – including fiendishly complicated paperwork and supervision systems – doctors generally very much want to provide excellent medical care and will generally take pains to do so if job conditions permit.

I don’t know what the answer is in the context of our present system. We do need a better payment system than the existing one. But pay-for-performance – I think – is another bad set of problems on the way, and an invitation to corruption.


Anonymous said...

So, You Want To Be A Doctor……

Lately in the media, others have said and appear to express concern about the apparent shortage of primary care doctors in particular. Typically, the main reason believed and speculated by others for this decline of this health care profession specialty that historically has been the apex of our health care system is lack of pay of this specialty when compared with other specialties chosen by potential physicians while in training, as the annual salary of a PCP is around 130 thousand a year on average, others have concluded may be the national average and factors in payers both of a private and public nature.
Yet considering the additional attention of shortages of students in some medical schools as well, as conceived by others, one could posit hat this professional vocation that has been one viewed in the not so distant past in the U.S. as one with great esteem and respect may not be desired as a vocation by many, that requires commitment and dedication, as reflected in their training regimen in the U.S. that consumes about a third of thier lifespan. Such reasons for this paradigm shift may include:
Primary Care Doctors perhaps more than other physician specialties seem to be choosing to practice medicine under the direction and financial security of one of the many and newly created health care systems These regional and nationally created systems are typically composed of numerous hospitals and clinics under combined ownership- frequently of a private nature that is not dependent upon their beliefs as it is perhaps on their profit motives and intentions. Yet their approach and etiology of their views regarding the restoration of the health of others are usually similar with such mergers of multiple medical facilities, which are presently preferred to save costs, it has been said, and therefore these systems have not been protested by a largely uninformed public.
Conversely and in addition, this system of increasing popularity is not necessarily a desired method to practice medicine as a primary care physician, often stated by them as members of their employer that has the power to limit and dictate how they practice medicine. This is because, among other reasons, such doctors have largely unexpected and unanticipated limitations regarding their patients’ heath provided by them. This is further aggravated by possible and unreasonable expectations of their employer, such as mandating that doctors they employ are required to see as many patients as theycan in a day, and there have been cases of physicians being fired by a health care system- along with financial rewards for seeing more patients a day than what is determined as average visits by others. Such requirements likely and potentially affect or alter the clinical judgment determined by physicians employed in what may be viewed as authoritarian employers, which would limit the medical care they provide to their patients, as well as the quality of this care. Also, such health care systems may have their own managed health care system that may be determined by factors not in the best interest of the patients of doctors employed by the health care system.
The primary etiology and stimulus for a doctor to practice medicine in this way is due to their frequent inability to provide and employ ancillary staff, combined with the increasing premiums for their mandatory malpractice insurance, which may make doctors financially unable to work independently.
Malpractice laws and premiums, which is determined in large part on a state level, are an issue with those required to have this adverse aspect of their professions. Also, these premiums become more expensive for doctors, depending on the perceived risk of their chosen specialty. For example, the premiums of an OB/GYN doctor are usually higher than one of a specialty viewed less risky for lawsuits, such as Dermatology, perhaps. Plantiffs win about 25 percent of the time on average a half a million dollars. 95 percent of these cases are settled out of court.
In addition, the issue of medical malpractice is also frequently a catalyst for a doctor to practice what has been called defensive medicine, which basically means that the health care provider is prohibited from relying upon their subjective factors in their assessment of their patients, which in itself raises the question of what the point was of all of their training in the first place. Because if a doctor practices medicine in such a way, it typically involves what may be considered as unnecessary diagnostic testing for their patients to rule out what may be unlikely disease states of their patients’ medical conditions. This waste of medical resources is further validated by the legality reflected in the tone of the notes a doctor usually annotates or dictates with their patients.
Such restrictions and limitations imposed on today’s primary health care provider are usually not fully illustrated during their training for this profession, which is one that has been viewed as one that is quite noble and of great responsibility on a societal level. It seems that this perception and vocation that now is greatly misperceived due possibly to being deformed by others who may have profit as their motive for the health care they may dictate to doctors they may employ in some way, which often and likely is in conflict with their motives as doctors and how they wish to deliver needed health care to others. This may be why this medical profession may no longer be viewed as distinct from other vocations, in large part, as it seems that presently the profession of a doctor has been reduced to one dependent on the financial stability and growth of its employer, which may alter how the doctors perceive what is expected of them as well, which may affect the importance of how they view their profession, as it has been said that overall, doctors are somewhat understandably more cynical and demoralized, which may be replacing the pride they historically have viewed their callings as doctors, as well as the perceptions of patients in the U.S. Health Care System.
Further complicating and vexing to these restrictions is the usual financial state of the individual physician, as theynormally have to pay off the debt acquired from attending medical school and training, which averages well over 100,000 dollars today after their training is completed, it has been estimated, along with this debt amount presently is about 5 times higher than it was only a few decades ago.
Conversely, there are some who believe that doctors in the U.S. are over-paid and are compared with some corporate monster, who behaves based upon the premise of greed. In spite of how they are judged, physicians are likely not absent of financial concerns- which may be of more of an issue than many other professions, comparatively speaking, in addition of taking on more responsibility that is of greater importance compared with other vocations. Such realistic variables should be factored in when one chooses to judge the profession of a physician. On the other hand, no physician should view their jobs as no different from any other venture capitalist when rationalizing their income and motives related to this exceptional vocation as a physician, as others are more dependent on their judgment.

It has been determined by others, and suggested often and lately, that many of today’s physicians practicing medicine in the United State do not recommend or speak favorably of their professions compared with their typical views of their profession in the not so distant past. While this self-perception physicians may have of a negative nature may be somewhat understandable it is also and potentially unfortunate for the health of the public in the future, and the nature normally associated with the medical profession which could deter ideal medical care for others
There have been cases where doctors do in fact change careers, and get into vocational fields such as medical communications or corporate medical companies. Also, expert witnessing is another consideration for those who choose to leave their profession. Finally, other choices considered include consulting and research. The training of doctors fortunately leaves them with options not involved directly with the flaws of medical care, but this is bad for us as citizens, overall. The etiology of their departure from their designed profession is largely due to the negative state perceived by themselves as well as others of their profession as medical doctors.
Then again, not all doctors are deities. Like others, some are greedy and corrupt, which complicates others in this profession in relation to how their vocation is viewed by others and based on limited judgment and analysis. Yet citizens overall should determine what sort of health care they desire, and it seems that often they fail to voice this right as a citizen.
For perhaps Primary Care Physicians in particular, the medical profession and those who provide medical care clearly needed by others to some degree appears to be absent as a desired path of today’s careerist. The authentic reasons for what many believe to be a negative perception of possibly the entire health care system may never be known, yet many would agree that most U.S. citizens are understandably concerned with the state of this system of great importance to society. Yet need to be active more in assuring this necessity is more aseptic.
“In nothing do men more nearly approach the Gods then in giving health to men.” --- Cicero
Dan Abshear
Author’s note: What has been written has been based upon information and belief of a layperson, yet also the assessments of a patient.

Anonymous said...

Regarding vaccines, we have seen a number of large drug companies buying vaccine and generic firms. Most recently a piece on how all adults are woefully behind on their childhood immunizations and how this is a national tragedy. The immediate solution is to, of course, submit to a complete cycle of new vaccinations.

While maintaining adequate protection against threats is a positive endeavor, the mass vaccination of the population has questionable benefits. When combined with pay for performance you end up with doctors trying to give you shots at every visit, regardless of stated desire or need.

Having spent nearly a whole office visit explaining that no means no and yes, I understood the health risk, one leaves the office with a very diminished view of the medical professional. Understanding the financial incentive for this action leaves one wondering about the doctors focus on patient care.

Pay for performance will have many unintended consequences, one of which will be the further erosion of a doctor's professional stature.

Steve Lucas

Anonymous said...

patient autonomy and shared decision making, (both pillars of medical ethics/professionalism) will be systematically degraded under current P4P schemes. More importantly, so will physician honesty.

If a physician needs certain outcomes to be labeled a "high quality provider" then selective advice will inevitably be given to achieve such outcomes. Why tell someone "the evidence is muddy here" or "your absolute benefit over 5 years will be 1-2% based on the study" when they might then politely decline the treatment offered? Instead, you will increasingly hear the physician say: "it's very important for your health that you do what I say and take this medicine or get this test." Many times that is simply not true, but why get bogged down in the details, eh?

Engaging the patient in the decision just increases the likelyhood that they make a decision that is counter to the needs of your "quality scores." Those patients who actually have opinions about their care and make individual decisions based on their values/preferences with input from the physician will be labeled "non-compliant" and become pariahs.

Considering such patients are often making a decision that reflects true quality care (appropriately individualized for the patient, using their input, weighing positives, negatives, arriving at a shared decision, etc), current P4P should be clearly understood as unethical.

Anonymous said...

Pay for performance? Bah! Humbug! The true title is "Pay for Conformance." Where's the incentive for innovative solutions? The mediocritization of American medicine continues ...

InformaticsMD said...

In fact, the sudden official leap to "universal electronic medical records" is probably in part fueled by a desire of payers to exert more control over the medical profession. EMR is a powerful enabler of P4P schemes.

The leap in 2004 to the establishment of a national Health IT office cannot be explained by the documented low diffusion and effects of health IT alone. Data on benefits are scanty, contradictory, and show a questionable ROI except in a few select organizations at work on health IT for many years.

The National Coordinator Office should have had as its primary purpose a "Plan of Study" to determine if national EMR was really necessary and even possible considering the state of the art in clinical IT.