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.