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Stop treating doctors like school children

As more doctor pay is being tied to patient satisfaction and “outcomes,” a recent Forbes article argues that “It’s only a matter of time before physicians will see the bulk of their compensation tied to quality measures.” To prepare for this pay-for-performance apocalypse, the article cites Medical Group Management Association (MGMA) CEO Haylee Fischer-Wright, MD, who urges physicians to “build data analyses” and take steps to “keep their patients satisfied.”

These sound bites might go over well in a boardroom (assuming there are no physicians present). But let’s consider two little problems. First: Neither pay-for-performance (P4P) nor patient satisfaction has been shown to improve patient outcomes. Secondly, and perhaps more importantly to shareholders, neither have been shown to save money.

P4P sounds great in theory — it’s the old “carrot and stick” routine, or something that psychologists call “extrinsic motivation.” Give doctors more money for good work, and they will work harder, do a better job with patients and voila! Better patient outcomes. Threaten them with pay cuts or other forms of punishment for poorer results, and they will fall into line.

Except extrinsic motivators, like cash rewards, don’t work when it comes to complex human behaviors. This may be why repeated studies of P4P have failed to show any meaningful improvement in patient outcomes. Increased test ordering, yes. More patient lecturing, sure. For example, if you pay doctors a little more, they will order more A1c tests and refer their patients to have a diabetic eye exam. But no study has shown that ordering those additional A1cs or nagging patients to get an eye exam improved diabetic control or decreased any meaningful endpoint like mortality, foot amputation or blindness.

Another problem with the use of extrinsic motivators is that they may actually reduce our own intrinsic drive to improve our performance, and may even provoke a desire to try to game the system.

For example, a JAMA article pointed out how easy this would be to do in a study reviewing physician “report cards,” a humiliating form of physician profiling performed by many insurance companies. Due to the nature of statistical scoring, one of the easiest ways for a doctor to improve his or her grade is to simply avoid or dismiss patients with the worst controlled diabetes or poorest adherence to treatment recommendations.

This is not something that most doctors would ever desire to do — but if the alternative were, in the words of the JAMA article, “pruning from their panel the 1 to 3 patients with the highest hemoglobin A1c level during the prior year” versus losing significant practice revenue, well … even the most well-intended physician might have to do some serious soul-searching.

Instead of using report cards, which penalize patients more than physicians, we should focus on what has been shown to work to improve physician care: training and education, specifically “well-designed, individualized continued medical education addressing specific deficiencies.”

And when it comes to paying doctors on patient satisfaction rates, we’ve got this completely backward. Studies show that “the customer is always right” philosophy is dead wrong, as more “satisfied” patients are more likely to spend time in the hospital, have higher overall health care usage, spend more money on medications, and worst of all, have increased mortality rates.

So, if P4P and doctor rating scales don’t work to improve patient care, what does?

The answer is this: Patient outcomes are improved when physicians spend time with patients — something we call “sustained continuity of care.” That means seeing the same doctor for your regular medical care, checking in every few months when you have a medical condition that requires monitoring like asthma, diabetes or hypertension and visiting that same doctor for preventive care visits.

Sustained continuity of care has been shown to improve quality of care by decreasing hospitalizations and emergency room visits, as well as by increasing preventive care. It also has been shown to improve care in patients with chronic conditions. And most importantly, continuity of care by the same doctor reduces mortality rates.

This means that we should be encouraging patients to see their regular physician rather than popping into a retail clinic or ER to see a staff “doc-in-a-box” or nurse practitioner for minor health issues. It means that we must stop incentivizing telemedicine consults with a random provider and instead encourage patients to consult with their personal doctor for health concerns.

To achieve improved health outcomes, we must stop looking at schemes like P4P, replacing doctors with artificial intelligence or lesser trained health providers, but rather focus our efforts on growing a robust physician workforce throughout the country. We must also help doctors to practice medicine unencumbered by non-value added intrusions, because physicians get the best results when they have adequate time with patients and when doctors are happier at work – general physician job satisfaction has been shown to improve patient adherence to treatment plans.

One more important factor improves patient outcomes: patients do best when their physicians show empathy for them. And doctors are better able to practice with empathy when they are not overworked and abused by a system of grading, data-mining, and threats of financial penalties.

So, let’s stop demeaning doctors by treating them like school children with report cards and financial bribes. It doesn’t work, it doesn’t save money, and it doesn’t help patients.


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