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.
See here for more discussion.

Tuesday, February 1, 2011

If Your Doctor Is "In It For The Money" And You're Getting Great Care, Where's The Beef?

Pay for Performance to improve health care quality is on a roll.  Maybe the assumptions are wrong.

A few days ago I submitted a post on Nostrums about a large-scale study done in the United Kingdom looking at a different way to pay physicians for providing health care.

As I explained, payment reform that emphasizes “outcomes” rather than services performed ( the old “fee for service”)—called “outcomes-based,” or in this case “Pay for Performance”-- has been touted as a way to improve quality in health care.  But it's also claimed `that it would act as a brake on costs, because physicians would no longer be motivated to do more than was needed.

In the US, believers in Pay for Performance (PfP) have gained control of the policy-making and are busily spending huge sums to implement outcomes-based payment. All of which assumes that there will be a positive impact on quality and cost. The study I described addressed that primary assumption that quality will improve when we incentivize payment toward results.

While no single study--no matter how good--can be definitive, there was little to criticize in the method. The study showed that if you look at the management of high blood pressure, both before and after a scheme for outcomes-based payment to providers and then looked at the quality of care the patients received, PfP made no difference in (1) how well the patients were monitored, (2) whether their blood pressure was controlled, and (3) the rate of complications that occurred in the population (strokes and heart attacks).

I thought at the time…and still do…that's enough of an input to cause us in the United States to pause as we're looking at reforming physician payment. That's not to say that reform of the payment system is not necessary, it's just that maybe this particular way of going about it is not the best, and doesn't incorporate other aspects of the delivery of healthcare that that need to be considered. See that post for more on the elements involved.

Coincidentally, I was rereading parts of a book I had read last year, Medicine and the Market: Equity v. Choice, by Daniel Callahan and Angela A. Wasunna. This valuable book avoids the politics and attempts to address the sometimes competing issues of equity and choice in the healthcare system. I found where I had highlighted a couple of quotes. This is the first.
Should I really care if my doctor is in it only for the money as long as he respects my dignity, treats me with empathy, answers my phone calls promptly, and provides me with high-quality care?
You frequently hear patients say, “He’s only in it for the money.” And certainly there are people who had the discipline and tenacity to endure 10 years of training for the primary purpose of making a great living or becoming wealthy. Too often it’s assumed that their motives corrupt their ability to provide the best care. But there’s no evidence of that. As in any career, there are scurrilous knaves, but almost all are not. The assumption that income has a corrosive affect on performance is false, because it conceals an underlying Romantic notion of perfect benevolence as a pre-requisite for good medical care.

However ethicists and policy makers have recognized for a long time that benevolence (not just empathy, but subordination of all other motives to doing good) is not achievable. To document this, the authors go back to Adam Smith (you remember The Wealth of Nations and the” invisible hand” of the marketplace from college, right?)
[Adam] Smith’s claim, as the historian Jerry Z. Muller has aptly put it, “is that an economic system cannot be based on benevolence, which is a limited sentiment not easily extended beyond those one knows.” ( from The Mind and Market: Capitalism in Modern European Thought, p 62). The great challenge, Smith believed, was to understand how to develop the potential social benefits of our propensity to self-love and self-interest. The market provides a way of increasing wealth while, at the same time, fostering social cooperation and valuable moral traits. Among those traits are discipline, delay of gratification, self-command, and prudence.
There's been a lot of interest in Adam Smith's work recently. Some experts are asking whether his formulation of self-interest could act in health care delivery as a social good. Referencing the quotation above, if your Dr. provides you with high quality care what difference does it make if she or he may be motivated by income?

On the other hand, if you insist that benevolence trump self-interest, other problems arise. Forcing benevolence in a global sense routinely collapses under the weight of coercion, patient dissatisfaction and regulatory interference.

If there was some way to say that good could come even in the absence of benevolence--leaving empathy in place, which all doctors are trained to evaluate and consider—and the result is high-quality medical care, what should it matter about payment?  Empathy is essential, see here for more.

I think this is a point that's worth considering, at least in the context of quality of care, particularly since it’s not clear that reform of payment using performance or outcomes will give us what we want..except more government agencies we don't want.

On the other hand, this says nothing about how physicians’ income motives can affect overall health care costs. That should be addressed. Solving the cost problem of ever-increasing demand will continue to be a challenge.
Many journalists and commenters want to demonize one or more segments of the health care system as a means of controlling costs: it’s the rapacious doctors, the evil insurance companies, the money-grubbing pharmaceutical companies, or the over-charging hospitals. All of this is useless class warfare, and is used cynically by politicians (who are pandering to ignorance, and know full well this is not the underlying cost problem.)

For those of you who subscribe to an “income disparity” view of the world, consider this: one economist said if we tax 99% of the income of the top 10% of the wealthy in this country, the money collected wouldn’t make a noticeable dent in the annual budget deficit.

Taxing the rich and cutting payments (or any type of price control) is ineffective. Most economists will agree that price-controls, price-capping and payment-reductions almost never result in a long-term cost reduction.

[SUPPLEMENT: I don't want to get into the psychology of how people make decisions about costs. Whether it’s buying a car or payment for medical services. This has been studied by psychologists for a long time. It's fairly clear that as human beings we are vulnerable to the influence of assuming that high-cost means high quality. And that's clearly not the case. Fixing our false tendency to think, if something costs more it’s worth more, is a seaparate problem, one that stems from defects in our reasoning, not problems in healthcare.]

When I step out of my doctor role, and enter the patient role, I look for competence and meticulous attention to detail in my doctor. If she/he wants me to come in for an appointment (for which they get paid) rather than prescribe over the phone (for which they don't), I’m OK with that. Their request accords with quality medical care; inconvenient for me, but they won’t overlook something by sliding on the need for a face-to-face assessment, no matter how simple or straightforward I think it is.

I won’t launch into my vision of healthcare cost, and payment reform in this post. I’ll save it for later. For the moment I’ll just assert that contrary to popular opinion, the government is the primary driver of cost increases, and that we do not have a market system for healthcare in this country. Au contraire, it’s one of the most highly regulated service systems we have.

Also, I won’t talk about the unintended consequences of performance based incentives at this point. There will be negative consequences: where there is a standard for care, but the patient doesn’t fit that standard, denial of payment will distort the incentive.  Again, for another post.

[BTW: what insurer has the highest percentage of claims denied? Nope, not a commercial insurer, it’s Medicare (over 6% denial rate; the commercial industry averages half of that…check it out.]

For now, we need to reign in the political warfare and fully investigate what will, and will not, work, before lurching down an unproven makeover of the huge and complex system we call US Healthcare.

Doc D

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