Wednesday, July 15, 2009

The Sticky Subject of Patient Responsibility

Over the last couple of days I've heard this suggestion on the radio: reimbursements for physicians should be restructured such that they are based on patient outcomes.

I disagree.

For almost any other profession or trade, payment is based on a certain expectation of skill and work. I don't wait till after a job is done to pay my carpenter or plumber; he or she charges a rate based on the "going" rate for the job at that particular level of training, and a job well done is expected. If a job is not well done, some money wrangling can ensue; but a priori the quoted rate is based on things other than outcome.

But that's not why I disagree. I disagree because a reimbursement system based on patient outcome makes the assumption that physicians are entirely in control of outcome, when the fact of the matter is some patients bring factors to a given situation that portend poor outcomes. Some of these factors - genetics, environmental exposure - are largely out of patients' control; others, however, derive directly from patients' habits and choices.

Reimbursement based on outcome completely absolves patients from any kind of responsibility for their own health. Physicians whose patients, for example, insist on smoking liking smoke stacks all day every day for decades would be punished merely for having such patients on their rosters. Reimbursement based on outcome would also punish those physicians whose patient populations live at increased risk for disorders such as asthma or malnutrition by virtue of their geographic or socioeconomic lot in life and would reward physicians who live in Gucciville, USA and practice at Dolce & Gabbana Hospital, simply because their more advantaged patients happen to be healthier.

One report I heard held up transplants, and the rigorous outcome measures applied for patients receiving them, as an example of why such a system would ultimately compel physicians to do better. I believe this is a disingenuous comparison; transplants are highly specialized clinical scenarios on which physician practices have direct, observable, concrete impact, but many of the situations that arise in primary care medicine depend as much on patients' actions as on those of physicians.

I firmly believe physicians should be responsible for the care they provide. I believe they should accept responsbility for shortfalls in care and always strive to improve. But I also believe patients, who so often voice the desire to be decision-making partners with their physicians, should also take some responsibility for their own health. If my primary care physician is going to have some dollars taken from her because my blood pressure is still high on my next visit, some dollars should be required of me to compensate her for the loss because despite her entreaties I have not been consistent about getting enough exercise, maintaining a healthy weight, eating a healthy diet, or what-have-you.

Physicians aren't all-powerful. They shouldn't be expected to work miracles, change genetics, manipulate temperament, cure addiction, or read people's minds when they are lying or failing to disclose all pertinent facts. We as patients need to do the work of taking care of ourselves, reporting our symptoms and habits truthfully, making efforts to improve our lives. Only then can the doctor-patient relationship be a kind of "partnering" interaction.

[Photo: painting by Jules Adler of a blood transfusion from goat to human, hanging above a huge staircase at the Université René Descartes.]


Old MD Girl said...

Hmmm.... While patients are in control of a large part of their outcome, I do think physicians should be compensated *in part* based on how their patients do. It's like having to pay a deductible, it's an incentive. Sure, we're not supposed to need incentives to do a good job (we're doctors afterall!), but the reality is that we're also people, and as such respond to incentives.

I also think the benefits to a little pay for performance outweigh the risks of having a few evil doctors drop their non-compliant patients. Chances are these evil patient droppers won't be as good at doctoring as the non-droppers and won't get the reward $ anyway.

T. said...

True, OMDG - I agree incentives could be a good thing, as long as there are some checks and balances built into the reimbursement system to correct for factors beyond our control.

HugeMD said...

I agree it's a sticky subject. Have to balance patient responsibility with what is out of physicians' control. Depending on how far it goes, I could definitely see docs being more choosy with their patients.

Would a surgeon have been less likely to have agreed to fix my rotator cuff because it's attached to my fat body with asthmatic lungs, a heart with a history of a couple episodes of SVT, an inherited clotting disorder... because I'm at higher risk of complications than someone else? I'd hope not, cuz it feels damn better. I'm in the process of losing the weight, but the other things I, and my docs, can only control to a certain degree. We did all we could preop to prevent any problems, but we all know complications can still arise...

Sister #1 Kathy said...

This is not a suggestion. This IS in the bill.

Transor Z said...

I think some practices are more conducive to this than others. For example, it makes sense for PCPs to be rewarded for improving metrics in preventive categories, like smoking cessation, weight, and blood pressure. Patient compliance is a big wild card but I'm sure you agree that for many treatments where you have a big enough sample size those idiosyncracies will wash out. I think your concerns go to appropriately defining "outcome" as it relates to the doc's contribution and is a good point.

gcs15 said...

Pay for performance is a huge disaster in the making. There are too many factors physicians cannot control. No matter how good a surgeon you are, you are going to have complications. No matter how good a GP you are, a significant percentage of your patients are not going to follow your advice.

It is horribly unfair to pay a physician less if he or she chooses to take care of high risk patients. These patients have more problems and require more work.

It is an insult for anyone to say that more money would improve doctors' outcomes. How many of us deliberately don't treat patients as well as we know how, as we've been taught how? How many of us don't continually go to conferences and do CME every year to learn the latest, best treatment options, at our own expense? How many of us don't take it personally when our patients don't do as well as we would like? Government is essentially calling us lazy, uncaring and unethical with this initiative. We should be angry!

Under pay for performance, care won't get better. Physicians will have no choice but to avoid taking on the care of the sickest patients. These patients will have to travel to tertiary teaching centers. Those centers will be swamped, more than they already are. Physicians will leave academic medicine in droves.

It's already hard enough to care for the highest risk patients due to the liability issues alone. Now, when you operate on a high risk patient, you not only get sued for it, but you also get paid LESS!

Finally, if you stick with caring for these patients, and you accept getting financially dinged for it, the pain and suffering doesn't end there. Next, you will be informed by the hospital consultant that you are a problem doctor, because your outcomes are below average. Your hospital privileges will be curtailed. Your outcomes will be made public, since part of pay for performance includes publicizing this data. Potential patients and referring doctors will therefore see that you are a "bad" doctor, and they won't come to you or refer patients to you. Poof, there goes your practice and your livelihood. You try to move to another state, but the hospital there won't give you privileges because they researched your outcomes and saw what a "bad" doctor you are. Think it can't happen? Think it can't happen to YOU?

The bottom line is, government needs to stop thinking it knows best, and it needs to drop this pay for performance disaster as of yesterday. Government can't control everything, and neither can we as physicians. All we can do is our best - and we're already running ourselves ragged doing just that.

T. said...

"It is horribly unfair to pay a physician less if he or she chooses to take care of high risk patients. These patients have more problems and require more work.

It is an insult for anyone to say that more money would improve doctors' outcomes. How many of us deliberately don't treat patients as well as we know how, as we've been taught how? How many of us don't continually go to conferences and do CME every year to learn the latest, best treatment options, at our own expense? How many of us don't take it personally when our patients don't do as well as we would like?"

Gcs15, you managed to get into a couple of paragraphs all the examples I couldn't verbalize as i was contemplating the conversations I heard on the radio. Thank you for putting my feelings into concrete terms!!

Transor Z said...

Wow, I'm hard-pressed to think of anyone else who holds themselves out to be morally above quality-based incentives in their work by virtue of the spiritually transformative power of professional ethics. How is the air up there?

T. said...

It makes no sense whatsoever to CENTER a system around "quality-based incentives" when top quality care is not necessarily always associated with great outcomes, and poor outcomes are not necessarily (perhaps, not even usually) due to sub-par care.

Medicine just doesn't work that way in real life. There's nothing "moral" about it.

Dreaming again said...

I seriously worry about this. Will I have trouble getting medical care if this becomes standard. I've got not one but 2 autoimmune diseases ... both unpredictible with limited response to therapeutic interventions.

Would a doctor be held accountable if I went into myasthenic crisis because it was 105 outside? (has happened)

It just can't be a good thing for people with certain chronic illnesses that are their own monsters and not obedient to the medical profession or the text books that taught the doctors.

Transor Z said...

Actually from your earlier comment I think we agree that outcome-based incentives can be appropriate where the scoring gives due weight to factors such as high-risk procedures.

But I'm going to call you folks out for advancing an argument that doesn't jibe with statistical analysis. My point earlier is that a doctor can reach outcomes-based benchmarks as a percentage of total population served, even with some negative outcomes.

The moral reference I made was to this notion that prevailing professional ethics sufficiently address quality issues without the "insult" of financial incentives.
There's no arguing the point that sometimes you just can't save people from themselves. But in the aggregate, good quality care will achieve beneficial outcomes. That's how standard of care is determined! LOL

As with all schemes, the devil is in the details. It simply will not do to argue to the exception/outlier when a compensation scheme measures performance in the aggregate.

The current financial model incentivizes denial of services. A more sane system incentivizes positive outcomes, which should be everyone's goal anyway.

Transor Z said...

Oh, and by the way, hate to break it to ya, docs, but oftentimes patient compliance is achieved by follow-up done by practice PAs, NPs, and RNs. So you might think about this as a business matter rather than in such intensely personal terms...

And yes, problem-solving around patient compliance to get good outcomes is part of your brief. If you can't be persuasive enough, hire a scary nurse to be your Enforcer.

T. said...

Dreaming Again - It's already happening. Doctors are held accountable for unpredictable drug reactions, for instance, even though statistics show that complications will happen some of the time NO MATTER HOW GOOD a clinician is (as gcs15 already pointed out). It's a great point, Dreaming Again - not all disease states follow the descriptions in the textbooks.

Most doctors who are worth their salt went into medicine because they genuinely care about taking good care of people. If they do less than their best at any given moment during their careers, human beings suffer, and lives could be adversely affected (or lost). I agree with OMDG that incentives IN GENERAL can motivate improvement, and people do respond to incentives, but in a system where you already HAVE to strive to do your best (and have to WANT to do so) every waking moment at work, because the work itself costs lives, the idea of using reimbursement as punishment or reward demonstrates a complete lack of understanding of the nature of the profession.

My concern is that such a system will in the long run betray the very patients who have the greatest need for medical attention - those with complicated and/or chronic afflictions who, by virtue of their illnesses, may not necessarily have good outcomes despite the provision of stellar care. If people erroneously equate "doctor lucky enough to dodge the complications predicted by statistics" or "lucky enough to live in a population of privileged, and therefore generally healthy, patients" with "good doctor," I fear gcs15's prophecies could very well come true.

Dragonfly said...

It could potentially be a disincentive for doctors to work in underserved areas with "difficult" patients (who may be so because of lack of education, psychosocial deprivation etc etc, where change may takes YEARS).

T. said...

Dragonfly, I'm glad you reiterated that concern. It relates to another point I wanted to stress (actually, REPEAT).

Which sounds better: "Most of the children in my practice are asthma-free" or "A third of the children in my practice have to go to the E.R. or be admitted for the asthma symptoms every year?"

It's all well and good if your "aggregate" consists of patients from places like Newtonville, MA or Irvington, NY, where a family practice doc might have to round on a pediatric patient with asthma just a few times within a certain period. But if your "aggregate" of patients is in Dorchester, MA or some other inner city neighborhood, the equivalent doc could be rounding on asthma patients several times a WEEK. I saw that contrast myself when I worked in two different pediatric hospitals, one in a white suburb, the other in the Bronx.

It's not the inner city doc's fault he or she is dedicated to the underserved and is dealing with a population disadvantaged by exposure to allergens that increase the risk for certain disease states.

Transor Z said...

Regional health disparities are a big problem. But we're talking outcomes, no? So outcomes for treating asthma patients need to be compared apples-to-apples with asthma patients as a group. Outcome data collection typically includes age, gender, ethnicity -- the usual demographic stuff. But you need to distinguish between higher incidences of illness in certain pops and treatment outcomes. Any incentive system would have to do that or I agree it would be foolish.

I believe that preventive metrics are measured solely against practice-specific benchmarks. But it would be silly to penalize docs for taking on a morbidly obese pt because s/he would skew the annual weight average. One easy solution is to reset the benchmarks annually and wait until the following year's reset to add new pts.

But I think we're in agreement that apples-to-apples outcome evaluations that adequately account for regional differences are essential.

It's also past my bedtime.

But one last thing: the people saving business is a red herring. That goes to base level of compensation, which prices in skill, stress, scarcity -- all that supply & demand stuff. I kinda doubt a PCP will be reduced to making Burger King money.


WarmSocks said...

It is appropriate to pay more money for good work than for mediocre work. However, paying one person based on the performance of a different person, is ludicrous.

Examples of how this would play out:
A student stays out partying instead of studying, and consequently does poorly on a test. Pay the teacher less - should've motivated the student to study.

Cities flouridate their water supply, but people in rural areas use unflouridated well-water. Dentists who treat patients in rural areas would be paid less when lack of flouride leads to cavities.

Ridiculous? Maybe, but that's what P4P sounds like. It is not the doctor's job to make people lose weight, eat balanced foods, etc.

We'll see a time when doctors require their patients to sign a contract, submit a food-intake diary, pass blood-tests proving they haven't smoked, and maintain an "approved" height/weight ratio, or risk dismissal...


A great post, and you are right patients do need to take responsibility for their weight, drinking, drug and smoking compensation.
However some doctors also need to also face responsibility when things go dreadfully wrong instead of blaming and or demeaning their patient.

T. said...

Agreed, Neoconduit - this was exactly the point I was thinking of when I wrote, "I firmly believe physicians should be responsible for the care they provide. I believe they should accept responsbility for shortfalls in care and always strive to improve."

Warm Socks - I really hope it doesn't come to that.

Transor Z said...

Folks, a successful model already exists for this kind of plan: the UK NHS's Quality and Outcomes Framework for PCPs(GPs). The major drawback of implementation was that UK PCPs achieved 90% of goals instead of the expected (and budgeted!) 70%, resulting in a cost overrun. IOW, the docs got paid more than expected through outperforming the goals.

Under QOF, physicians are permitted to exclude patient data in cases of noncompliance, outlier conditions in which they do not tolerate or do not respond to standard medications, and new patients.

For QOF outcome data see:

T. said...

It sounds like they DID build into that system, then, the "checks and balances built into the reimbursement system to correct for factors beyond our control" that I already mentioned in my first comment above and have been advocating all along.

There has to be a way to account for those things that have already been mentioned many times in the post and on this comment board that do not allow for a level playing field.

Anonymous said...

Sounds like "No Child Left Behind," doesn't it? Teachers have no more control over how prepared students are coming in, or what they do outside of class (meth vs homework), but are held responsible.

And most parents are convinced their little darlings are all above average and should score really, really well.

Transor Z said...

Your lead paragraph and bulk of your post attacks P4P based on the faulty assumption (or strawman) that it necessarily holds doctors accountable for things that are beyond their control. You'll forgive me for attaching little weight to your hedge position that P4P with "checks and balances" might be okay. The subsequent comments by you and a few others were supported only by "parade of horribles" scarefest rhetoric.

"More matter with less art." Let's have some data-driven positions. The importance of the subject really demands it.

Anonymous said...

Speaking of education: you talk about going to a private school; perhaps you send your kids to a private school.

One of the ways private schools have good showings (ACT/SAT scores, college acceptances) is by cherry-picking students. They simply don't accept kids with behavior problems, autistic kids, severely disabled kids.

The cherry-picking there means your kids gain a huge advantage. But you don't have a problem with that?

Why is it acceptable when it benefits you/your kids, even though it disadvantages all the kids at public schools (where such students are accomodated, even though it may cause disruptions for a lot of students)?

T. said...

My kids go to public school.

I could do a whole other blog post about problems engendered by meritocracy, but that's another subject for another time.

Old MD Girl said...

Anon 7:13 -

Wow. Way to bring out the personal attacks. Sheesh.

gcs15 said...


It appears you and I will have to chronically disagree on this issue.

This may well be the only profession in which morals incentivize quality of product. We as physicians take the Hippocratic Oath before receiving our MD degree. Our motto is, "First do no harm." These are not empty words. Few go into medicine for the money; the vast majority of physicians actually want to help their fellow humans. How many other professions require an oath before starting work? The clergy, perhaps, but they're not making daily life-and-death decisions.

Dangling a few extra dollars in front of us doesn't change our commitment to our patients or our professional behavior. Yes, it does insult me to suggest otherwise, and I'm sure I'm not the only one.

You talk about statistical analysis. One thing I learned in statistics is that you can manipulate the data to say anything you want it to say. A study can be seriously flawed but still have results that appear compelling. Similarly, an individual doctor's outcome data can appear below average even though the physician is very skilled and very effective.

You mention Britain's QOF and tout the results, but I would point out your admission of the several factors they exclude. I suspect these exclusions probably skewed the data significantly. I doubt CMS is likely to allow such exclusions. And what are their criteria for deciding that a patient is noncompliant?

No, family practitioners won't make Burger King money. However, they won't be able to keep the doors open because their expenses (liability, taxes, and unfunded government mandates included) will soon outstrip their collections. It's happening right now to physicians in my community.

Medicine is so regulated even in the US that the market doesn't work normally. If it did, payment for our services wouldn't be going down every year or so even as our jobs require more and more education and skill.

In the U.S, the current financial model from a physician's point of view incentivizes provision of services, not denial of them. Insurance companies are certainly incentivized to deny services, but physicians are not. In the UK, the incentive is for government-salaried physicians to work as little as possible (which appears to translate into denial of services). Hence the long waits for many procedures and the difficulty of access to specialists. That's not a system I want to emulate. And, yes, I have personal experience with that system.

Thanks, I'm aware of the "standard of care." I practice according to it every day. If I don't, I get sued, and I lose sleep because my patients don't do well.

And the air up here is just fine. I work long and hard every day to keep breathing it.

I don't pretend that our system is perfect. I just have major problems with this pay for performance disaster that will cause far reaching problems government can't possibly predict (like EMTALA).

Finally, I love the comparison of P4P to No Child Left Behind. Ask any teacher how that's helped their students' test scores and their job satisfaction.

Lawyerdude said...

Another apt analogy might be commercial pilots who are going to do their best to keep their passengers safe regardless of any incentives. It has nothing to do with their morality, but everything to do with their chosen profession. They are well paid because we demand of them years of training and perfect outcomes.

Transor Z said...

In a system that rewards certain outcomes without efficiently attributing causation, it's equally true to say that doctors will be unfairly rewarded for positive outcomes they did little to achieve. Why assume a bias that injures doctors?

But this is just a semantic point to highlight two related goals of this and virtually all other regulatory schemes: control over industry outputs that maximize public benefit while minimizing negative impacts and, secondly, achieving those goals as efficiently as possible. The US track record shows a clear preference for heavy private sector involvement in all industry regulatory schemes. Utilities, finance (ahem), FDA, and on and on. In Massachusetts, by law the preliminary panels that review malpractice claims for merit must include physicians. If history is any guide, doctors should have little fear that outcome metrics will be dreamed up by bureaucrats with dartboards. Far more likely that you will see American Academy of Pedriatrics and WHO child immunization target levels used.

Again, my objections to this post stemmed from the faulty reasoning that outcomes-based incentives are necessarily a net negative. If T. takes the position that an efficient system would be okay then I agree.

With regard to the taking of sacred oaths, personally I put more faith in the power of a driven Type A/OCD personality than in whatever ceremonial oaths/secret handshakes s/he may have performed. If that kind of magical thinking helps soothe cognitive dissonance and gets you through the night, more power to you. But when I buy a health care service I'm buying the probability of a set of outcomes, not buying into the AMA brand image of the gentle doctor with healing hands. Save that stuff for the brochures and ad campaigns.

T. said...

As I've already stated in other ways here, I don't believe a reward/punishment model for payment in medicine (or in general) is appropriate.

People study, train, work hard, get educated to do work that others will not or cannot do. They should be paid for THAT. For example, having seen first-hand what they go through, I think the fact that neurosurgeons earn way more than other doctors - than almost anybody, excluding Wall Street CEO's, Hollywood actors, and star athletes, in fact - is completely fair. Who can operate on someone's brain? Not too many people. How long did it take to be able to do that? At LEAST sixteen HARD years after high school. I think their training, abilities, and relative scarcity are worth a lot. They SHOULD be paid for it.

Finally - of all the disrespectful, snide-toned, patronizing, cynical comments you've made here, Transor Z, your dismissal of physicians' genuine commitment, symbolized by the Hippocratic Oath, as "magical thinking" to soothe "cognitive dissonance" (whatever the heck you imagine you mean by that) demonstrates perfectly what you've spent days already proving: you don't just have a "bee in your bonnet" about doctors, but rather, utter contempt in your heart/mind/spirit/whatever term you prefer. You might be a little more effective in reaching others with the points you want to make, and undermine yourself and your credibility less, by trying a little less disdain and a little more respect.

Transor Z said...

T., any contempt or disdain I feel is targeted at sanctimonious attitudes and not at all the broad brush you suggest is "proven" by comments I've made here. Whether my style is a good fit for this blog is entirely your call. I have dear friends who are doctors. There are also doctors I don't much care for. Most docs I know personally skew republican/libertarian politically and are avid followers of their investments and the economy generally. We would never throw our respective professional oaths in each others faces to support a business issue. I don't think that makes me or them "cynical," but we've certainly all been around the block a few times.

In my own defense I'll only say that I seem to be an antidote to an "Amen corner" feel to commentary here. When you move into the wild blogosphere you never know what the cat will drag in.

But for all your very ad hominem take on my comments, I think I raise some very fair points I'd be interested in reading responses to.

T. said...

Transor Z -

If the "Amen corner feel to commentary here" doesn't suit YOU, perhaps this isn't the forum for you. While I think you've made some very interesting points above and elsewhere, which can lead to some really valuable exchanges, there are moments when the WAY in which you make them betrays a highly negative attitude against the people you're trying to engage in the discussion. Not all the time, of course, but enough times to be significantly distracting and, on occasion, off-putting. (I am basing these remarks not only on this comment board but also on the extensive one at this post:

I WELCOME lively discussion and disagreements, and for the most part, readers of this blog are able to engage in just that with maturity and dignity, as requested on the Main Page (items #2 & 3 under "Practicalities"). Most of them also "get," and don't have to be reminded, that it's my party/virtual home, and they are guests, and they thus treat me and my other guests with courtesy and respect. That atmosphere may feel like an "Amen corner" to people who aren't used to engaging in disagreement without the need for sarcasm or petulance, but I honestly think it's just ordinary courtesy. Not everyone who leaves comments here agrees with what I write; most people, though, don't feel the need to insult the members of my profession in order to make their points or feel comfortable in the discussion.

I believe it's rather disingenous to claim "style" as an excuse for discourtesy and unpleasantness, especially when the capacity for a perfectly gracious "style" clearly exists. Comments don't have to be directed ad hominem to be offensive; I am not alone in finding your occasional (but recurring) snide tone objectionable.

As for valuable points, to REPEAT: it almost doesn't matter how good your points are if you make them in a way that repels receptiveness. Don't imagine you do us (by being such the "antidote") or yourself a favor when all you do, AGAIN, is undermine your own effectiveness with the unevolved spirit demonstrated by an attitude of disdain. Contempt is a losing proposition and is ultimately always unproductive, whereas respectful disagreement, which I welcome, can actually generate growth and insight.

You've suggested in the past that physicians have some responsibility for how they come across to others. That holds true for everyone - not just physicians.