Doctors Should Be Paid for Outcomes. But Which Outcomes?

flying cadeuciiShould we 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 healthcare.

There is too little discussion about patients’ free choice or responsibility. Both in medical malpractice cases and in the healthcare 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 healthcare. 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.

And that will be the topic of my next installment…

Hans Duvefelt, MD is a Swedish-born family physician in a small town in rural Maine. He blogs regularly at A Country Doctor Writes where this piece originally appeared.

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7 replies »

  1. you cant argue with business people, they are immune to facts, (kind of like liberals) but they are big on buzz words like wellness, medical home, quality, patient satisifcation etc.

  2. Seething with common sense.

    This line is key:

    “What kind of bureaucracy would it take to create a payment scheme that factored in such things?”

    The answer to bureaucratic failure is more bureaucracy, then even more and then more still.

  3. Along with the excellent points you make about the uncertainty of basing payments on outcomes you touched on the problem of statistical significance. With all the variations and permutations that abound in primary care offices I don’t see how any payment scenario based upon disease outcomes could be statistically significant. Flipping a coin would be a lot less expensive and probably just as accurate.

  4. It’s even more alarming when the Administration doesn’t follow the recommendations of its own comission.

  5. I agree completely that it is lost on the outcomes police that a useful/valuable outcome is often a result of perspective. For example, in a patient with chronic low back pain, return to work is not an outcome that is necessarily valuable to the health plan, but it is damned important to the employer. If that same patient is overweight and deconditioned, the solution to his problem might not be perpetual NSAIDs, or laminectomy, but weight loss and conditioning exercises. What outcome will you meaure and report then?

    The problem with outcomes is that it is now just another buzz word. Unfortunately, as the author correctly points out, people with the power of the purse, come to rely upon buzz words to make decisions.

  6. Very good points – of course these will be lost on the bureaucrats and politicians that control the system.

    How about this – the salary of the Surgeon General and all the employees of CMS will be linked to national health care statistics?

    “Sauce for the goose is sauce for the gander”