Two separate articles appeared this week in JAMA (the Journal of the American Medical Association) reporting that financial incentives either to individual physicians or group practices might improve the overall quality of care delivered to patients. I guess it’s human nature, especially viewed through the eyes of a lifetime Chicagoan like myself, to think, “Well of course bribes work (sorry, financial incentives)…unless you’re caught.”
You slip the guy with the snowplow $20 and the street in front of your house gets cleared before your neighbor around the corner. Generally, 20 bucks to your mailman ensures your copy of Vogue won’t be buried in a snow bank.
But gosh, do we really need such thinking when it comes to our health? Wasn’t there some sort of oath taken after medical school graduation that excluded this sort of pay-for-play (perfected by literally dozens of Illinois politicians over the years)? Apparently not.
“Financial-based performance enhancement”
Large sums are being spent on both sides of the Atlantic to find out if doctors do a better job if their palms have been greased before they slide on the surgical gloves.
The answer, of course, is that whether you want really good seats for the next Stones gig or you want blood pressures lowered, bribery pays. Is anyone really surprised that doctors are exempt? For a bit of extra cash your doc (also, BTW, your pharmacist and local hospital) will go the extra mile for you. Naturally, it’s not called a bribe. Now it’s a (get this) “financial-based performance enhancement.”
The two recent JAMA studies, and other similar ones published over the past few years, all work the same way. Investigators select one or more readily measurable goals for physicians to meet. Blood pressure control, for example, or lowering cholesterol or hemoglobin A1C (a blood test that monitors diabetes management). In a hospital, it’s usually early discharge days or post-op surgical wound care. In nursing homes, measurable nutritional improvements among the frail elderly.
Divide the participating physicians, hospitals, and nursing homes into two groups. Set an end point like “patient blood pressure under good control within three months.” Pay each doc in one group a C-note for every patient of theirs meeting the goal. The other group of docs gets nothing–ashes, cinders, and their usual not-unsubstantial paycheck.
If your doc knows he’s getting the $100, he’ll make sure your blood pressure plummets (maybe even if you didn’t have high blood pressure in the first place). Wait, did I say that? I’m sorry for even suggesting such nefarious behavior is possible.
EMRs smooth the way
The current (and mandatory) switch-over to electronic medical records (EMRs) now lays your health wide open to the Big Brothers of the government and health insurance industry. Don’t bother with any hand-wringing about this–they’ve known about your health status for years. You probably don’t remember signing a release form when you got your group insurance. You were so happy to be employed you’d sign anything. And you did.
With EMRs, observing and monitoring a physician’s activity is pretty basic stuff, especially in a big group practice in which all doctors enter data into a common system. Smaller practices like WholeHealth Chicago are more challenging to monitor since, amazingly enough, no two EMRs are alike and interpractice communication is virtually impossible. But yes, when financial incentives were in place, researchers discovered that when promised a crisp hundred dollar bill for getting a patient’s numbers down, the doc went that extra mile. Better yet, the bigger medical groups, guaranteed annual bonuses of $100,000 or more, did their jobs even faster.
The “unintended consequences of performance incentives”
Before I move on to what one investigator ironically called the “unintended consequences of performance incentives,” I’ll answer a question I’m sure has crossed your mind: whose money is paying for all this? For the time being, in both the US and the UK, it’s government money (which means, of course, we’re paying). The rationale, and it’s not necessarily bad reasoning given that chronic illness is so costly (think Medicare), is that as long as we’re spending these billions trying to make people well, why not see if some redistribution of the largesse can make the system more efficient.
Although these performance incentive systems are currently in place in government-funded programs only (Medicare, the Veterans Administration, and the National Health Service in the UK), here in the States the major health insurers (Blue Cross, Aetna, United) have their own performance incentive programs in place and are watching these studies carefully.
The “unintended consequences of performance incentives” referred to earlier varied from study to study. Each involved a tweak of the system to allow the doctor to get an even bigger bonus. In Chicago, aldermen frequently suffer the unintended consequences of performance incentives by doing jail time.
The unintended consequences for you personally could be less severe than jail, although theoretically you could die. Let’s review some of these unintended consequences…
- There was a tendency to over-diagnose relatively innocuous conditions and begin treatment quickly. This is called “lowering the diagnostic threshold” and you can immediately see the danger here. You may remember I wrote about the recent revelation that the “normal” blood pressure of 120/70 had been determined during a World Health Organization meeting decades ago that was financially underwritten by a drug company introducing its latest blood pressure med. From that moment on, too many doctors started their patients on a lifetime of medication for the relatively harmless blood pressure of 140/84 (and remember BP is always higher in a doctor’s office). If a doc is getting $100 every time she lowers 140/84 to 120/70, which she can do easily with a couple of cheap generic meds, in a few weeks she can start eyeing that Caribbean cruise her husband has been badgering her about. Is your cholesterol 230? Lipitor 40 mg (generic!) will bring it to 140 and the doctor’s check is in the mail. My personal favorite of these examples was the UK nursing home that had diagnosed their frail elderly with kwashiorkor, that gruesome state of starvation you see among near-dead children during a famine. After a couple weeks of simply feeding their patients, the home received incentive bonuses for curing kwashiorkor.
- With the over-diagnosis, there was over-treatment. Medications work faster than lifestyle changes. It’s easier for a doctor to start a smoker on Chantix and get the $100 smoking cessation bonus than it is to recommend counseling or hypnotherapy. Three weeks of generic Prozac and the depressed patient qualifies as “better” and the doc doesn’t have to spend all that bonus money subsidizing some psychotherapist. With a little imagination, you’ll notice how the serious winner in the incentive pay system is, of course, the pharmaceutical industry.
- Along with over-treated patients, the losers in this system are two groups of doctors. One group (and I’ve written about this before) are practices with extra-sick patients who aren’t compliant about taking meds. Some programs financially penalize physicians who fail to bring down abnormal numbers and the outcome is that non-compliant patients find themselves “fired” from certain practices. The other losers are practices like WholeHealth Chicago, which has healthy patients and physicians who prescribe lifestyle changes over medications. How so you get a bonus for a smoking cessation program when you have a practice of non-smoking patients? As one British GP wrote in response to one of these studies “There is no good reason why doctors should take home less for providing good care” and branded the whole incentive pay system “perverse.”
- The electronic medical record system is highly vulnerable to fudging data for personal gain. A dishonest doctor could simply enter 150/100 as your blood pressure on your first visit, make a note that he has counseled you to lower your salt intake, and then, on your return visit, enter your correct (normal) blood pressure. The monitoring system picks up “improvement within guidelines” and he can watch the mail for his bonus.
Personally, I think some sort of warning system to patients about these financial incentives is in order. A few amendments added to that ubiquitous Patient’s Bill of Rights you see in hospital lobbies should warn you that the hospital’s CEO will be bonused if you’re discharged early, even if you collapse in the parking lot.
Such information might convince you to have your heart transplant elsewhere. Or, doctors nationwide could wear buttons on their white coats:
• YOU 120/80, ME $100
• YOU Lipitor, ME Paris
• Your Pap test, my bonus
David Edelberg, MD