A doctor described to a colleague a long-term patient who he had seen earlier in the week. She has diabetes that can be controlled but has failed to come into his office regularly even though he has contacted her many times. The doctor is highly ranked on quality measures that the local health insurer has laid out for evaluating and paying physicians to improve medical care and cut costs. Yet the doctor asked this colleague about his infrequently seen diabetic patient: “She just can’t afford to take that much time off from work. Does that make me a worse doctor?”
In pay-4-performance plans established by Medicare and private health insurers, the basic assumption is that, yes, what a doctor does has a direct effect on patients’ health. But what patients do or do not do is not part of that assumption. For example, many of the measures used to rank and reward doctors come from guidelines drawn from extensive research studies that are designated as “best” practices such as patients getting regular mammograms, Pap smears, screening for high cholesterol, diabetes, high blood pressure, and colon cancer. Health insurers want physicians to use these evidenced-based practices to standardize delivery of quality care, improve health of patients, and reduce medical costs. Health insurers, at the same time, also evaluate and pay doctors on the frequency in use of these evidenced-based practices. Billions of public and private dollars are now invested in evaluating doctors’ performance and paying them. Like so many businesses, the belief that were individual incentives distributed on the basis of performance employees and professionals will work harder and do the right things for their customers and clients.
For those familiar with the trajectory of well-intentioned policies aimed at changing individual and institutional behaviors, unintended consequences occur as predictably as windy days in Chicago. Policymakers are stuck, however. They just don’t know which unexpected consequences to anticipate. Although when it comes to using money as an incentive to change behavior, much literature exists on what happens when results for hospitals, surgeons, and medical procedures are reported publicly. Some astute decision-makers might have figured out ways that any such policy could be gamed by individuals and institutions (see WillP4PandQualityReportingAffectHealthDisparities).
No surprise, then, that unexpected consequences have stuck thumbs in the eyes of policymakers and insurers on pay-4-performance plans. For example, Medicare requires—as a quality measure—that doctors administer antibiotics to a pneumonia patient within six hours of arriving at the hospital. As one physician said: “The trouble is that doctors often cannot diagnose pneumonia that quickly. You have to talk to and examine the patient and wait for blood tests, chest X-rays and so on.” What’s worse, he continues, is that “more and more antibiotics are being used in emergency rooms today, despite all-too-evident dangers like antibiotic-resistant bacteria and antibiotic-associated infections.” He and other doctors know that surgeons have been known to cherry pick reasonably healthy patients for heart bypass operations and ignore elderly ones who have 3-5 chronic ailments to insure that results look good.
Also medical researchers know far more about the effects of low-income, under-insured, and non-English speaking patients when doctors are ranked on the quality of care they render especially if rewards or penalties follow such rankings. One study involving 125,000 patients revealed that who doctors cared for affected their rankings for pay-4-performance plans. Those doctors who cared for older or sicker patients were ranked higher (probably because of frequent follow-up, behaviors that received higher rankings) than those doctors who cared for minority and under-insured patients who saw doctors irregularly. Which patients are cared for, then, affects rankings.
In light of emerging evidence that untoward outcomes occur when cash incentives are put into place to evaluate, rank, and reward individual doctors, pay-4-performance schemes have raised disturbing questions not only about the basic assumption that what doctors do determine effects upon patients but also about the assumptions driving pay-4-performance plans for individual teachers based upon student test scores.
Although both doctors and teachers are in helping professions, many differences separate them from one another in their training, daily work, the scientific basis for what they do, societal respect, and accountability. Nonetheless, there are some striking similarities insofar as evaluation and pay-4-performance policies. The next post takes up these similarities.