nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
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Thursday, January 27, 2011

Study Undermines Assumption That Payment Reform Can Improve Quality

Another assumption of health care reform rebutted:  that quality of care will improve if doctors get paid for what they accomplish, rather than what they do.

This is the so called "outcomes-based" or "pay for performance" proposal.  The quality solution to the nefarious "fee for service" system we currently have.

Pay for Performance (PfP) carries the kind of simplistic logic that avoids getting into the details of the complex interactions in health care delivery.  The premise is that (1) doctors get paid to do stuff, (2) doctors want to get paid more, (3) doctors will do more stuff to get paid more.   This will result in unnecessary and potentially harmful tests, surgeries, and treatments.  So quality will suffer.

Despite refuting false claims about health care quality being poor in the US (see my posts here and here), the media and activists have been largely successful in portraying the US health care system as giving poorer results than abroad.  In fact, longevity and infant mortality, two of the most common comparisons, are better.

But given that most people now assume the critics are right, it makes things easier for them to propose changes that have the appearance of  being "a good idea," when they may not be.

Enter Pay for Performance (PfP):  to reverse the incentives to perform too much, and potentially harmful, care; to change the payment system--pay only for results, or "outcomes."

Take the example of high blood pressure (hypertension).  Pay for Performance would reward physicians if they met certain standards for whether a patient's blood pressure is checked regularly and is controlled, whether they follow standard protocols for what drugs are used to control the pressure, and whether they reduce the number of complications in the patients they are taking care of (strokes, heart attacks, etc). 

As I say, it all sounds very straightforward.  The incentives are shifted from income to outcome:  keeps doctors focused where they should be, eliminating care that's not needed.

There've been a few limited experiments that show quality improvement under such a scheme, but they've all been criticized on the basis of the Hawthorne effect, small study size, and other issues.

Now, there's a large scale research project out of the UK, looking at hypertension, where Pay for Performance resulted in no improvement in quality.  The authors conclude,
"Governments and private insurers throughout the world are likely wasting many billions on policies that assume that all you have to do is pay doctors to improve quality of medical care," says senior author Stephen Soumerai, professor in the Department of Population Medicine at Harvard Medical School and Harvard Pilgrim Health Care Institute. "Based on our study of almost 500,000 patients over seven years, that assumption is questionable at best." (Science Daily, Jan 25)
Note the scale and duration of the study (available here, BMJ Jan 25).  They looked at over half a million patients from 2000 to 2007 not only to have a large denominator, but also to ensure a comparison to the non-PfP results prior to implementing the scheme in 2004.  The date range included data for three years prior to implementing PfP, and three years after, for comparison.  There was no change in blood pressure control or in complications from the disease.

For Onion Peelers,
After accounting for secular trends, no changes in blood pressure monitoring (level change 0.85, 95% confidence interval −3.04 to 4.74, P=0.669 and trend change −0.01, −0.24 to 0.21, P=0.615), control (−1.19, −2.06 to 1.09, P=0.109 and −0.01, −0.06 to 0.03, P=0.569), or treatment intensity (0.67, −1.27 to 2.81, P=0.412 and 0.02, −0.23 to 0.19, P=0.706) were attributable to pay for performance. Pay for performance had no effect on the cumulative incidence of stroke, myocardial infarction, renal failure, heart failure, or all cause mortality in both treatment experienced and newly treated subgroups.

The separate question, whether it saved money, is not addressed.  But even so, PfP is being sold as a correction to poor quality...which didn't occur.

As another author put it, in the same Science Daily piece,
"Doctor performance is based on many factors besides money that were not addressed in this program: patient behavior, continuing MD training, shared responsibility and teamwork with pharmacists, nurses and other health professionals. These are factors that reach far beyond simple monetary incentives."
Quality improvement is a critical effort.  Lobbyists, politicians, and advocates for PfP are diligently implementing expensive programs as we speak.

Wouldn't it be better to validate the concept first?  Maybe look at some of the other contributions to quality that interact with payment?

Doc D

UPDATE:  Omitted a duplicated paragraph.


james gaulte said...

Thanks for another great blog posting.
James Gaulte

Doc D said...

Thanks. You could probably teach me a lot about incentives. I'm not against them, and used them as HC CEO, but I'm wary. Incentives work unpredictably in complex systems, particularly HC, where the goal is good health and well-being, a state of being that is unique to each individual. Some economists seemed obsessed by incentive management, but HC bears no relationship to pricing in automotive sales. I'm putting up a quote later today that tries to put together some of my thinking about how to approach quality/safety/cost/access.

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