Should doctors be paid for outcomes?

This is often proposed, but I have trouble understanding it. Real outcomes are not blood pressure or blood sugar numbers; they are deaths, strokes, heart attacks, amputations, hospital-acquired infections and the like. In today’s medicine-as-manufacturing paradigm, such events are seen as preventable and punishable.

Ironically, the U.S. insurance industry has no trouble recognizing “Acts of God” or “force majeure” as events beyond human control in spheres other than health care.

There is too little discussion about patients’ free choice or responsibility. Both in medical malpractice cases and in the health care debate, it appears that it is the doctor’s fault if the patient doesn’t get well.

If my diabetic patient doesn’t follow my advice, I must not have tried hard enough, the logic goes, so I should be penalized with a smaller paycheck.

The dark side of such a system is that doctors might cull such patients from their practices in self defense and not accept new ones. I read about some practices not accepting new patients taking more than three medications. In the example I read, the explanation was not having time for complicated patients, but such a policy would also reduce the number of patients exposing the doctor to the risk of bad outcomes.

A few comparisons illustrate the dilemma of paying for outcomes.

Do firefighters not get paid if the house they’re dousing to the best of their ability still burns down?

Does the detective investigating a homicide not get a paycheck if the crime remains unsolved?

Does the military get less money if we lose a war?

Even if we were to accept and embrace outcomes-based reimbursement in health care, how would we measure outcomes?

We already know that an episode of care, say a hospitalization for heart failure or a COPD exacerbation can seem successful, but the 30-day readmission rate can cast doubt on that. First, of course, not all of that outcome is dependent on a single provider or even a group of providers, but involves ancillary staff, hospital resources and much more. This is one of the thoughts behind the accountable care organization movement. Second, much of what happens in sickness and in health is not provider-dependent at all. An unusually miserable weather pattern can make COPD relapse rates higher one month than the next, for example.

What kind of bureaucracy would it take to create a payment scheme that factored in such things? And would our health care dollars really be better spent on such accounting efforts than on nursing staff levels or something else?

Other than short term outcomes for gallbladder surgeries, pneumonia hospitalizations and such discrete episodes of care, how would we measure outcomes, for example in primary care and disease prevention?

For pediatricians, would we follow their patients’ health into old age to determine how good their early care was? How about when patients switch doctors, often because of insurance coverage changes — who gets the credit or blame for future bad outcomes?

In short, I think outcomes-based reimbursement works only in a limited sector of health care. For primary care, and specialty care that spans over any length of time, we need to get back to basics in the form of honest pay for honest work.

“A Country Doctor” is a family physician who blogs at A Country Doctor Writes:.

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  • Dr. Drake Ramoray

    Pay for performance is bad for doctors and bad for patients. Especially in underserved, poor, rural, or inner city areas. The benchmark you use is relatively irrelevant.

    http://www.nytimes.com/2014/04/28/us/politics/health-laws-pay-policy-is-skewed-panel-finds.html?_r=1

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Pay for performance is not really aimed at improving outcomes the way plain folks understand the word outcomes. The goals are to standardize processes, reduce utilization of services and cut compensation for labor, all of which have been shown to reduce costs and expenditures in “other industries”, by producing cheaper goods and services of lesser quality.

    • Dr. Drake Ramoray

      But Accountable Care Organization and Patient Centered Medical Home sound so folksy and all American. Surely the innovators of such illustrious ideas that “focus” on the patient have nothing but good intentions. /s

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        Where is Norman Rockwell when you need him…

  • NewMexicoRam

    This is what I heard once:
    In ancient China, as long as the patient was living, the doctor was reimbursed handsomely.
    But if the patient died, well……you know.

  • HJ

    It’s interesting you chose public employees to make your point.

    I know we like to blame lazy patients for all the poor outcomes but there are situations where the doctor makes a poor choice and still gets paid. Not only does the doctor get paid they also get paid to fix it. Would you pay your plumber if he didn’t fix your clogged pipe? Or your mechanic if your car wasn’t fixed.

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