There are three problems with healthcare incentives and they all revolve not around the stated goal of pay for performance, but around the atmosphere that incentives produce.
Everyone wants to improve healthcare outcomes (or should) and providing incentives which reward physicians for achieving these goals would appear to be a good thing, but as is usually the case, the devil is in the details.
Problem #1: The commoditization of healthcare
When I went to medical school, we were taught that “good medicine is the best defense.” This meant that the reward for good medicine is practicing good medicine. Yes, doctors made a good living, but that living was not a reward for good medicine, but a reward for being a good doctor with all that the term “good doctor” entailed (competent, caring, compassionate, etc.) Changing the emphasis from “good medicine” and “good doctor” to dollar signs simultaneously changes healthcare from a service and a calling to a commodity to be bought, sold, and squandered.
Problem #2: Goals created in a vacuum
“Best practices” and “treatment goals” are the end points and rulers against which physician performance are measured in a “pay for performance” environment. These “best practices” and “treatment goals” are based on the conclusions of scientific studies. Patients enrolled in scientific studies typically suffer from only a single illness, the one that is being studied. In fact, the scientific method requires that patients be “normal” in all other ways. This is why subject recruitment is so difficult in scientific studies.
The problem is that in real world medicine, most patients have more than one illness. (An old medical “law” known as Silvagni’s law reminds us that there is no law in medicine that states you can’t have more than one problem at a time). It is not uncommon to have a patient with multiple diseases and find that the multiple sets of “best practices” that are incompatible. Of growing concern is the effect of polypharmacy (multiple prescription medications) which is the natural outgrowth of attempting to comply with all the “best practices” for a single patient with multiple diseases.
Problem #3: The mechanization of medicine
A growing trend in certain practice environments is the use of non-clinical, non-healthcare benchmarks to evaluate physicians. We are all familiar with “patient satisfaction surveys” which are actually exit polls. A survey is a scientific sampling of a representative subset of a larger group. An exit poll is the interrogation of everyone at the end of the care encounter. In a survey, if a person of a particular demographic fails to respond, they are replaced by another person with the same demographics. In an exit poll, if someone fails to respond, there is no one to replace them and thus the entire context of the poll changes. In a survey, if the representative demographic group is not recruited, the survey is invalid. If an exit poll has poor response, the results are still reported, even though they are invalid. Since those who are disgruntled for any reason are four times more likely to respond to an exit poll than those who are satisfied, the results are always skewed against the healthcare provider. This results the modification of medical practice to improve scores, not care. Towards this end, many emergency rooms are offering guarantees regarding wait times and even how long it will take to be treated.
Emergency room directors in these institutions are forced to encourage ER physicians to “just get face time in as many rooms as possible as quickly as possible, then get history and physicals later.” I personally have heard this in several ER’s and in only one was this advise part of an effective plan that positively impacted patient care and outcome. In all other situations, this admonishment was given to ensure that “the times look good.”
The purpose of a DOCTOR is to provide the best medical care possible within their skill set and after a scholarly and objective review of the literature. The measure of a PHYSICIAN is the ability to perform the functions of a doctor with humanity, humility, caring, compassion and love. Perhaps we should find a way of incentivizing physicians, not doctors.
