Tuesday, July 29, 2014

Why Pay For Performance Doesn't Work

The New York Times had an editorial the other day asking why the government's pay for performance initiatives haven't worked out as planned. By penalizing bad outcomes and incentivizing good outcomes, the government hoped to save money in the long run. Paying doctors to have fewer patients getting readmitted within thirty days after hospital discharge or making sure patients get the proper treatment for acute MI or pneumonia sounds like a reasonable way to reduce healthcare costs.

Yet according to the newspaper article, multiple medical studies have failed to show any change in outcome. Though initially there may be an improvement in quality measures such as patients getting adequate blood glucose monitoring, over the long term there are no differences between doctors who get incentive pay and doctors who don't.

Scientists and politicians are puzzled by this stasis. Why don't patients do better when doctors are given more money, or in reality penalized for not following "best practices" policies? The blame always seem to lead back to physicians. Doctors are just too stubborn. They won't change their practice after working the same way for decades. Doctors make too much money. A few dollars extra per patient is not enough to get them to follow the new government mandates. Doctors are cherry picking the best patients, leaving the sickest to the tertiary hospitals and their employee physicians to treat and who are the least likely to be affected by the new incentives.

I think the reason pay for performance hasn't worked as well as planned is also the most obvious. Let's face it, doctors are already working as hard as they can to give the best possible treatment to each and every patient we meet. We are not holding back our care just because we feel the reimbursements are inadequate, which they are. For any given patient and illness, we do our utmost to ensure the patient has a good outcome. Whether the patient is a homeless person who comes into the ER for an acute MI or the local millionaire who is fishing buddies with the city mayor who comes to the ER with the same thing, we treat each person's illness the same. Now the bedside manner and hospital amenities may be different between the two, but taking care of the chief complaint will be unsurprisingly similar. In fact, when I have a VIP patient, I have to mentally tell myself to treat this person no different from anybody else. Any deviation from my usual standard practice just because the person on the operating table is the mother of the hospital CEO is when catastrophe can occur.

What happens when the patients are discharged is something different and beyond the control of physicians. The millionaire may be able to afford a home health nurse who can attend to his needs 24/7. The homeless person will probably go to a shelter but quickly check himself out and stop taking his medications, necessitating a quick readmission in the emergency room. But that is not the doctor's fault even though we and the hospital are the ones who get money taken out of our pockets for it.

But don't concierge doctors give better care because patients pay them more money out of pocket? In a word, no. Patients buy better access to doctors in a concierge service. There is no evidence that concierge medicine is better medicine. Patients may feel they are getting superior treatment because they have their physicians' personal cell phone number and can arrange for an appointment at any time, but that is not the same thing as getting better health care.

So this puzzlement about why pay for performance doesn't seem to be effective is no mystery to any working doctor. Only the most cynical politicians and lawyers would devise these pay for performance initiatives. We are already doing the best we can with what we get. We don't mistreat patients just because they don't have enough money. Giving us more money is not going to change how we have practiced successfully for years. The people who are making these rules are the least qualified to tell us how to take care of our patients. Is it any wonder that P4P has been a failure so far?

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