Contaminating medicine with mercenary incentives

Some time ago, I endured a medical staff meeting, where attendance is taken and 50% attendance of all meetings is required. I learned that they are serious about this rule when, a few years ago, I was demoted from active staff when I failed to attend enough meetings. This demotion did not demoralize me, as I was only losing my right to vote, which I did not regard as a cherished right with respect to voting on hospital affairs. I learned later, however, that the hospital’s insurance panels all required active staff status of its physician members. I decided that the right to make a living superseded the right to vote. My attendance lapses were remedied and my honor was restored.

Today, a hired consultant was advising us on the importance of improving our patient satisfaction scores. Which of the following reasons to improve were offered to the staff, all of whom regard ourselves as paragons of the medical profession? As in all standardized test questions, choose the best answer:

  1. Improving patient communication improves medical care
  2. Self-criticism is an important exercise for physicians to pursue regularly
  3. No reason needed. We should simply do as we’re told
  4. It will give the hospital PR folks something to crow over
  5. None of the above

While there are many reasons that we physicians should want to improve our relationships with patients, making more money shouldn’t be our primary motivator. Yet this speaker ended his remarks emphasizing that these scores would be directly tied to the hospital’s reimbursement. Of course, this model will be extended to physicians’ offices also. There is something very ignoble about contaminating a noble profession with mercenary incentives. To me, it is doing the right thing for the wrong reasons. I recognize that my idealistic view is vulnerable. It is difficult to reject financial reward to spur physicians to satisfy our patients if nothing else motivates us to do so.

In our hospital, OB/GYN scored extremely high over the past 18 months that measurements were taken. Internists and hospitalists scored low, even lower than surgeons, who are not known for their cuddly bedside manners. I would like to post the graph of all specialties and their scores on this blog, but I fear it is proprietary and would place me in violation of several bylaws. After my prior demotion over medical meeting attendance, I cannot risk another confrontation and the public sanction that would follow. They might withdraw my privileges to perform rectal examinations, which would decimate a gastroenterologist’s practice.

There is a website that should be bookmarked by everyone reading this blog. The Hospital Compare site allows users to compare side by side, hospitals in your neighborhood with respect to patient satisfaction and other measurements. I strongly urge that readers spend some time examining data that your local hospitals are likely omitting in their glossy brochures that they use to promote themselves. The three community hospitals I attend all scored below the national average on the criteria being measured. In fact, using the standard grading scale used in high school, these hospitals would have received a failing grade. For example, only about 65% of patients at all three of these hospitals would definitely recommend the hospital to others. The website also presents other important data on patient outcomes, medical utilization and Medicare payments.

These data can be extremely useful to our profession. They can shake us up and encourage us to reflect and improve. All of us want to be the best we can be. What will it take to get us there? Will we do so because we recall Francis Peabody’s famous aphorism delivered nearly a century ago?

The secret of the care of the patient is in caring for the patient.

Or, will we need to be paid off.

Michael Kirsch is a gastroenterologist who blogs at MD Whistleblower.

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  • John C. Key MD

    “Making money” is not necessarily “mercenary”. It can be a useful metric, and it is also necessary to “make money” in order to keep one’s practice going. If you go broke, you can’t attend many patients. Doctors need not apologize for making money, in virtually all other professions it is an accepted mark of success. In medicine we have our own scarlet letters: the NPI and UPIN numbers. In other fields the entrepreneur is praised for offering “high value added services”. I’d venture to say we’ve all known the occasional colleague who seemed to have only financial motivations, but in my experience that percentage is relatively small.

  • Dike Drummond MD

    Thanks for the post Dr. Kirsch … and I hope you are open to a different viewpoint because I cannot understand the phrase, “contaminating a noble profession with mercenary incentives”.

    I have several questions for you
    1) Have you ever accepted money for your services – you are contaminated by your above criteria. Next question …
    2) Have you ever noticed how “the system” does not pay you for quality – in most cases it pays for the simple delivery of the service … the more services you deliver, the more you get paid. In short it pays for “quantity”.
    3) Have you ever noticed how the way people get paid will motivate their behavior
    If I pay for quantity, people will start doing more of whatever I pay them for. That is the current healthcare reimbursement system in a nutshell.

    What you are witnessing is an imperfect attempt to align payment with the delivery of quality care. If you were to get paid for quality, that payment would not be the ONLY REASON YOU PROVIDE A QUALITY SERVICE. There is no CONTAMINATION going on here. Payment for quality becomes one of many reasons you practice the highest quality medicine possible.

    My two cents,

    Dike Drummond MD

  • GTWMA1

    I don’t see contamination. I see reality. Money has always been one of the many motivations for all people. Physicians are people, too. They’ve always been motivated by money, among many other things. There’s no reason not to use money as one of the many reasons why they should focus on improving quality. And there are good reasons to find ways to make sure that money remains only one of many motivations for physicians to do their best for patients.

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