More Evidence that Pay for Performance is Working

DrRich | April 29th, 2010 - 8:57 pm

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DrRich has long praised Pay For Performance as a particularly effective tool for covertly rationing healthcare.

Traditionally, pay-for-performance efforts (modeled after time-honored techniques used on trained seals), produce checklists of approved “activities,” which physicians of quality will always perform when engaged in a “patient encounter.” By examining filled-out checklists, the payers (both health insurance companies and the government) can thus determine which doctors are of sufficiently high quality to deserve their full reimbursement allotment, and which doctors are of substandard quality, and therefore deserve at least to have a portion of their reimbursement withheld, and possibly to be sent away for “re-education,” or to have their names published on a potentially embarrassing list.

When these pay-for-performance checklists are combined with the need to see one patient every 7.5 minutes, thus leaving no time for the discussion of health problems (or other issues) that the payers have not seen fit to include on their checklists, pay-for-performance becomes a very serviceable addition to the covert rationing armamentarium. Which brings us to the latest good news about the success of pay-for-performance.

This week, at Digestive Disease Week (the year’s major scientific gathering of gastroenterologists), doctors from Johns Hopkins will present a paper demonstrating that pay-for-performance reimbursement schemes create financial incentives for surgeons to shun obese patients.

Under this species of pay-for-performance, surgeons are “rewarded” (i.e., not punished) for meeting specified quality standards which have to do with certain patient outcomes. (For pay-for-performance to occasionally equate quality with outcomes is a particularly useful formulation, since expressing reservations about such pay-for-performance measures immediately brands one as being against good medical outcomes, in the same way that being concerned about illegal immigration brands one as being against immigrants, or having reservations about certain of President Obama’s policies brands one as being a racist.)

The Johns Hopkins researchers have found that performing surgical procedures on obese patients results in substantially more complications than performing the same surgical procedures on non-obese patients. For instance, fat people had 27% more complications after gall bladder surgery, and 11% more complications after appendectomy, than thinner people. They also had substantially longer hospital stays, and generated much larger medical bills. The researchers conclude that surgeons (some of whom are literate and understand rudimentary statistics, and therefore not only have access to this kind of information, but are also capable of processing it to at least some extent) can only conclude that, in order to maintain a viable surgical practice, they will need to avoid operating on obese patients. At the very least, they will need to avoid doing elective surgery on fat people, waiting instead until they are in extremis, and require emergency surgery (since at least some effort is made to “adjust” the expected outcomes in these situations).

This result, of course, is similar to the result DrRich reported some time ago regarding the publication of Physician Report Cards. Namely, thanks to publicly-available report cards, cardiologists in the state of New York have been more reluctant than cardiologists in other states to aggressively treat patients with severe heart attacks, and as a result (while the report cards are cleaner) the mortality of these patients is higher in New York.

And the situation with surgeons being quite similar (i.e., doctors being incented to avoid treating higher-risk patients, for fear of being punished because of an unavoidably higher rate of complications), DrRich feels quite confident in offering his surgical friends the same advice he offered the New York cardiologists. Namely, he suggests the Designated Driver strategy.

The Designated Driver strategy requires the Chief of Surgery (ideally, an imposing and feared figure) to approach a promising young surgeon who is just entering practice after the end of a very long course of training, and saying, “Son, you are going to have a brief but spectacular career. You are going to be our Designated Driver.”

For an extraordinary annual salary and immediate vesting in a generous pension plan, this young surgeon is going to have the honor of being the one who gets all the high-risk surgical cases for the group. He will agree to do this as long as it is feasible, that is, as long as he’s not run out of practice because his pay-for performance reports, or his physician report card, have become so abysmally bad. With careful management, and with his colleagues tossing him a few “easy” cases now and then in order to extend his longevity, he may be able to survive as a surgeon for five or ten years (longer, for instance, than the average NFL player), after which he can enjoy a lucrative retirement, or simply change careers. (There are obviously other approaches for conducting the Designated Driver strategy, for instance, as a way for surgeons nearing retirement age to go out in a blaze of glory. But you get the idea.)

The Designator Driver strategy is a win-win for everyone except the government – so surely it will eventually become illegal. But what doctors have to realize, when practicing medicine in a healthcare system driven by the covert rationing imperative, is that one either gives in to the bizarre incentives created by programs like pay-for-performance (which will cause measurable harm to their patients), or one fights back guerrilla-style, striking where one can, and changing tactics as the enemy adjusts.

To the government, however, such guerrilla activities amount to a mere nuisance, an annoyance which (like the poor and the uninsured) will always be with us. Looking at the big picture, our government will doubtless rejoice to hear the Johns Hopkins research results. The Feds will be particularly pleased to learn that their pay-for-performance efforts are achieving both of the desired effects (i.e., reducing the volume of elective surgical procedures, and advancing prospects for demonizing and discriminating against the obese.

Say what you will about pay-for-performance. It’s working.

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