Some CEOs get paid by how much profit their companies make, and servers in the U.S. get rewarded through customer tips. Should doctors get paid the same way?
Two new randomized trials, published this week in the Journal of the American Medical Association, suggest that paying doctors according to how well they do their jobs could improve their patients' outcomes moderately. The studies come at a time when many experts are looking for new ideas for bringing down the U.S.' health care costs. The Affordable Care Act—the Obama Administration's health-care overhaul—already includes some pay-by-performance measures, for instance by tying hospitals' Medicare reimbursements to patient-satisfaction surveys.
Right now, U.S. patients mostly pay depending on the services they get—so much for a checkup, so much for an MRI scan, and so on. This system can motivate some doctors to order unnecessary procedures for their patients. After all, they're getting paid for every procedure they do. That drives up health care costs for everybody. So over the past few years, several research groups have examined whether paying doctors by their performance would work better. In 2011, the Cochrane Collaboration, a nonprofit that rigorously reviews studies about medical procedures, found there was insufficient data to say yea or nay for paying doctors by how well they work.
Both of the new studies looked at using bonuses to motivate doctors to do the right thing in preventative care.
In one of the new studies, researchers from New York and California examined 84 New York City clinics with fewer than 10 doctors each. They gave half of the clinics bonuses when doctors did things like give heart-disease patients aspirin prescriptions, control patients' blood pressure, and get patients to quit smoking. These things all help reduce patients' risk for heart attacks and strokes.
Clinics got higher bonuses for more difficult-to-treat patients, including those who had more than one condition and those who were uninsured. At most, the clinics received $200 per patient, up to $10,000 per clinic. One of the study's authors, Naomi Bardach, explained in statement why she and her colleagues rewarded doctors with more complicated patients: "The worry about pay for performance programs that pay only if physicians meet the quality target, is that the financial incentive discourages physicians from caring for more complicated patients," said Bardach, a physician at the University of California, San Francisco. "This program did not penalize physicians for patients they were caring for whose blood pressure might be more difficult to control than others."
The researchers found that compared to control clinics that didn't get bonuses, the paid clinics did indeed give out more appropriate aspirin prescriptions, start more smoking patients on quitting programs, and control their patients' blood pressure better. The researchers wanted to encourage these behaviors, so according to their study, this counted as good performance. In their paper, the researchers called the improvements "modest."
In another study, a team of U.S. researchers analyzed 12 Veterans Affairs clinics. At different clinics, the researchers aimed bonuses at individual doctors, at the entire clinic, or at both doctors and the clinic at the same time. A control group got no monetary incentives at all. The researchers awarded clinics and doctors for controlling patients' blood pressure.
They found that doctors who got bonuses were more likely to get their patients' blood pressures within recommended guidelines and to respond correctly to patients who had uncontrolled blood pressure. Bonuses for clinics didn't make a difference, however, and the bonuses didn't affect which blood-pressure medications doctors prescribed, nor the number of patients who came out the other end with low blood pressure.
What's next? Hopefully more data, or maybe an update to the Cochrane review of pay-for-performance studies. Meanwhile, the idea of paying doctors by patient outcomes remains controversial. The Wall Street Journal published a good point-counterpoint about it in June. One researcher said pay-for-performance works with doctors, while a physician said (correctly) that the data isn't there yet to prove it does work. The doctor was also afraid that pay-for-performance might undermine doctors' inner motivation to do well without extra pay—but there's no research backing that up, either.
Absolutely agree!!! If my insurance company paid my waitress, that delivers my food, I would never get good service. Good doctors are ones that have exhausted their determination of what's wrong with you. This requires, usually, better tests than those your insurance is willing to pay for. Therefore, your health is what gets affected. A new health model where doctors are paid, in part with incentives, for doing a good job, is much a better model in my opinion. This would force doctors to use the most "deterministic" tests for you. This would include genetic/DNA testing. My doctor getting paid to say "I can't find the problem", or treat a minor problem while doing expensive tests, is unacceptable and is a reason that healthcare costs are so inflated. Doctors are greedy too, make no bones about it.
Thank you Obama, at least your fracturing of the health care system will at least allow the model for expensive health care, for those with money, to grow and be the ideal for the masses. To those with little money... sorry, you get "Kaiser" like care, which is a good example of the model for Obama care. Sad and I hate Kaiser.
"Do not try and bend the spoon. That is impossible. Only try and realize the truth - there is no spoon."
Doctors are a poor model for health care. If civilized countries wanted to provide good care they'd abolish the current way doctors are used. The current way is more close to a mom and pop store. The best candidates for doctors are not usually the ones who end up being doctors.
I often wonder about the US centered approach to studies on health and education. The claims are that we're behind in both areas. But, instead of trying to adopt some of the methods used elsewhere, somebody invents a new method.
Performance payments seems like it could be an incredibly complex system. Also, who is paying?
I also have some issues with the oft repeated claim that docs order extra tests to up the old cash flow. I'm certain that there are unscrupulous individuals, but I wold think that there are 2 more likely reasons.
1. The docs genuinely think that the tests are required.
2. Malpractice lawsuits -- I'd really like to see some stats on the costs of lawsuits as a percentage overall health care.
So apparently it's a bad idea to pay doctors for being competent?
As someone who works in the health care field I have to say that this idea of paying doctors based on their patients outcomes is an incredibly foolish idea. What everyone seems to be forgetting is that people should be held responsible for their own health. No matter how often a doctor tells their patient that they need to stop smoking, they are unable to force the patient to do so. If the doctor wants their patient to change their diet, start exercising, or try a different medication in order to improve their cholesterol, blood pressure, or obesity the responsibility for following through lies with the patient.
To say that doctors are greedy is ludicrous, these are people who have given up a decade of their lives to learn the knowledge and skills necessary to improve and save the lives of others. While I will agree that some rare individuals slip through who aren't well suited to be doctors and are only in it for the money, the overwhelming majority chose that career because they genuinely want to help others.
If you really want to improve health care and lower costs the two good things to do would be first to go after the people who abuse the emergency department rather than try and make an appointment with their own doctor, and second put caps on malpractice lawsuits and allow some kind of recompense for doctors who have their credibility harmed by frivolous and fraudulent lawsuits.