The precarious peril of pay-for-performance


As a primary care pediatrician, I am often on the front line of mental health care. Since child psychiatric referral services are sparse and overloaded, I often have to initiate counseling for anxiety in many of my patients. One thing that I have learned is that you can help someone with anxiety in a tremendous way by getting them to recognize a simple fact: It is counterproductive to worry about things that we cannot change. We need to acknowledge the things that we can change, the things that we have control over, and recognize that we cannot control everything. This simple truth can lift a tremendous weight.

The new normal for physicians entails that our livelihood will be increasingly based on things that we cannot control, thus increasing the anxiety level of an already frazzled profession. I am an advocate for complex case management: I think that it is wasteful to not coordinate resources in the care of a complicated patient. The problem is that, as pediatricians, the vast majority of our patients do not have multiple chronic illnesses and do not fit a paradigm of complex case management. They do, however, have some pretty “non-algorithmic” things happen to them that do not fit seamlessly into a treatment paradigm. As a primary care pediatrician in Eastern Kentucky, I have a great deal of patients whose parents prenatally chose to expose their developing infant to harmful substances and who postnatally continue to make unhealthy choices, despite caring and compassionate counseling.

This concern extends to physicians who take care of older patients that refuse to quit smoking, or refuse to take prescribed medications regularly, etc. At some point, we as a society must acknowledge that there are consequences for our actions. However, we seem to want the freedom to make whatever choices we want and to have someone else bear the burden of the consequences.

Imagine that your local service station was contracted on a capitated basis to provide for your vehicle service needs. The station takes great care of your vehicle (and has extended service hours to accommodate your busy schedule!), but you choose to fill the gas tank with dirty creek water and to randomly shift into reverse while cruising along. Is it the station’s global package responsibility to fund and staff an educational team to train you how to take proper care of your vehicle? Or should you bear at least a modicum of responsibility for your irresponsible behavior?

In what I can survey, there is no mention of personal responsibility in the new normal; everything is someone else’s fault. Our motto should not be “the patient is always right” but instead should be “we will always do what is right for the patient.” This can lead to some uncomfortable discussions, that even though artfully and thoughtfully delivered by an actively listening physician, some patients will not find to their liking and respond with negative customer satisfaction surveys.

Another concern with rewarding physicians for having healthy patients is that many physicians will not want to take care of really sick patients because these cases will hurt their numbers. So when will the very patients who desperately need a medical home require care, where will they go? To the already overloaded ER to receive fragmented care. The same ER bound by EMTALA laws to provide a screening exam or face penalties. Then, when the visit is judged retrospectively to be non-emergent, the ER is reimbursed a non-sustainable rate. This is killing rural hospitals. But I get the impression that flyover country doesn’t matter much to the powers that be. This new normal looks oddly abnormal to me.

Ish Stevens is a pediatrician.

Image credit:


View 3 Comments >

Most Popular

✓ Join 150,000+ subscribers
✓ Get KevinMD's most popular stories