Should Physician Pay Be Tied to Performance?

[eridani]

No: The System Is Too Easy to Game — and Too Hard to Set Up

http://www.pnhp.org/print/news/2013/june/should-physician-pay-be-tied-to-performance

By Steffie Woolhandler, M.D.
The Wall Street Journal, June 16, 2013

Paying doctors for better care — not just more of it — seems like a no-brainer. Yet rigorous studies of pay-for-performance bonuses have found no health benefits and some unintended harms.

An exhaustive analysis of pay-for-performance research by the Cochrane Collaborative, an international group that reviews medical evidence, unearthed "no evidence that financial incentives can improve patient outcomes."

Consider these cases. In Britain's massive pay-for-performance program, family doctors earned almost perfect scores (and big bonuses) for hypertension treatment, but population surveys found no decrease in blood pressure or its main complication, strokes. Meanwhile, aspects of quality that didn't bring bonuses deteriorated.

The largest U.S. pay-for-performance experiment — Medicare's Premier Demonstration — also flopped. The 200 hospitals that offered bonuses scored slightly worse on patient death rates than other hospitals.

Proponents argue that programs like these were flawed in one way or another, and that the next trial — or the one after — will certainly do better. They also claim successes with other programs. But none of these claims rest on rigorous science, and all those that have subsequently been subjected to rigorous tests have failed.

[Squinch]

1. NO That would guarantee that it would be impossible for chronically ill people to create a

relationship with a doctor. The frailest patients would have the hardest time getting a doctor. It's like tying teacher pay to measured performance, in which those teaching the children with the most needs are least likely to satisfy the performance requirements.

Doctors should be salaried as in the Mayo Clinic. It eliminates conflicts of interest. And as your information shows, pay for measured performance doesn't improve outcomes.

There are certain fields where the corporate "produce or be fired" model is just dumb.

[no_hypocrisy]

2. Ancient Chinese paid their physicians ONLY WHEN they were well.

http://www.seekwellness.com/wellness/reports/2003-10-15.htm

It makes sense to me. If you're not well while being treated, the physician doesn't have incentive to help you.

[Warpy]

3. It always turns into pay by head count

I've seen the best care given by gerontologists who take on the frail elderly, the population most given to developing complication after complication. Bringing them through a serious illness takes incredible skill and it's pretty amazing to watch. However, they're generally poorly paid because the head count is lower and so is Medicare reimbursement.

Some docs are paid more, the "stars" in various surgical specialties. Again, the skill set is amazing, but patients often feel like they're on an assembly line into and out of the OR, actually seeing the great man only when they've been knocked out, PAs doing all the preop and postop care.

So good luck on trying to evaluate physicians by outcome. The gerontologist is always going to have the numbers indicate poor outcomes because of his patient population. The "star" surgeon will always come out on top, operating on a younger and healthier population.

[bemildred]

4. We need to reform our entire health care system.

This sort of piecemeal idea, while good, won't do much in the same old money-is-all health care system.

[quadrature]

5. the Obama Care Pathway ...

no thanks!

[LeftishBrit]

6. No.

Firstly, how do you define 'performance'? The number of patients who recover completely? But that would lead to doctors avoiding or undertreating patients who have a poor prognosis for complete recovery; e.g. the very elderly and those with chronic health conditions. The number who survive? While penalizing 'killer doctors' sounds like a good idea at first sight, it would mean that doctors would avoid risky procedures or risky patient groups, even if the patients accept the risks.

Whatever measures were chosen, it would lead to doctors choosing to fulfil these measures rather than others - this already happens with excessive 'target setting' in many professions. When teachers were 'paid by results' in the late 19th century, this led to teaching to the test and ignoring subjects that were not tested. The same would happen with the medical profession.

To get the best doctors:

Select them properly

Train and educate them properly

Supervise/ manage them properly

And ensure adequate funding to have enough doctors and other medical staff!