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Subject: qotd: Replace volume with quality?
Date: Mon, 17 Jun 2013 10:44:00 -0700
From: Don McCanne <email@example.com>
To: Quote-of-the-Day <firstname.lastname@example.org>
The Wall Street Journal
June 16, 2013
Should Physician Pay Be Tied to Performance?
No: The System Is Too Easy to Game—and Too Hard to Set Up
By Steffie Woolhandler
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
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.
No Easy Measurement
Why do these programs consistently fall short? Measurement is distorted
once you pay doctors based on the data they themselves create. High
scores may reflect real excellence, but can just as easily reflect
cherry-picking or gaming the measurement system.
One Boston-area hospital we observed improved its quality score 40% just
by getting doctors to change the words they wrote in patients' charts.
Medicare gives hospitals more credit for saving patients with "acute
respiratory decompensation" than those with "COPD exacerbations,"
although these terms are synonyms. That kind of practice is neither
illegal nor unusual.
Beyond that, it's devilishly difficult to quantify doctors' performance
in the first place. Hospital death rates seem, at first glance, an ideal
measure of medical quality. Yet, four widely used algorithms yield
completely different mortality rankings; a hospital rated outstanding in
one often looks downright dangerous in another.
Even if—as some proponents argue—we find performance measures that work
for one group of doctors, it's unlikely that they'll work for all
providers in all patient populations. Moreover, many providers interact
in providing care, and influence each other and patients' outcomes in
complex ways. It's hard to imagine that incentives could optimize this
as a system.
There's also psychology at work. Rewarding performance ignores the
complexity of human drive, particularly the role of intrinsic
motivation—the desire to perform an activity for its own inherent
rewards. Offering your dinner-party host a $10 reward for cooking a
wonderful meal isn't likely to motivate future invitations.
Studies have found that financial incentives often crowd out intrinsic
motivation. For instance, college students will spontaneously play with
interesting puzzles, but once they're paid to solve them, they lose
interest in playing for nothing. When day-care centers in Israel imposed
fines on parents for picking up children late, tardiness increased.
Promptness transformed from a moral duty to a market transaction.
Pay for performance undermines the mindset required for good
doctoring—the drive to do good work even when no one is looking.
Moreover, it forces doctors to shift their attention from patients to
computer screens—documenting trivial details useless for patient care
but essential for compliance.
None can doubt medicine's grave quality problems. As a remedy, pay for
performance suggests manipulating greed. This can certainly change
medicine, but not necessarily in the ways that we would plan, much less
(Dr. Woolhandler is a physician and professor at the City University of
New York School of Public Health. David U. Himmelstein, also a physician
and professor at the School of Public Health, and Dan Ariely, the James
B. Duke professor of behavioral economics at Duke University's Fuqua
School of Business, contributed to this article.)
Comment: We keep hearing over and over that we are going to have to
quit paying physicians based on the volume of their services and pay on
the quality of those services instead. There are two problems with this.
The first problem is that there is a certain volume of health care that
needs to be delivered. If the physician is told that quality counts but
volume doesn't, then wouldn't that physician be motivated to cut back on
work done? Does anyone seriously suggest that sloth is fine - payment
would be the same regardless of the volume of work? Of course not.
Whether fee-for-service or salaried, the physician is going to have to
The second problem is that the abstract concept that physician pay
should be tied to quality does not translate into a practical model of
measuring and rewarding quality. Physicians already attempt to provide
the best quality they can under the given clinical circumstances.
Typical measures selected are only a infinitesimal sampling of the
entire work product of the physician. Today's article explains the
deficiencies of trying to come to any conclusion about quality based on
The counter opinion to the article above was written by François de
Brantes, executive director of the Health Care Incentives Improvement
Institute, and is available at the same link above. Some of his comments
are instructive: "show poor outcomes in some pay-for-performance
trials," "design flaws," "doctors were rewarded for results that were
actually poor," "it has worked, if not always as well as it should,"
and, "problems can be fixed by not letting providers set benchmarks." If
physicians, with their conflicts of interest, don't define quality, then
who does? The MBAs? Is that really better?
We definitely must address medicine's many quality problems, ideally
through beneficent public policies, but manipulating greed through pay
for performance schemes is not the way to get there.