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The Pitfalls of Linking Doctors’ Pay to Performance

By SANDEEP JAUHAR, M.D

Not long ago, a colleague asked me for help in
treating a patient with congestive heart
failure who had just been transferred from
another hospital.

When I looked over the medical chart, I noticed
that the patient, in his early 60s, was
receiving an intravenous antibiotic every day.
No one seemed to know why. Apparently it had
been started in the emergency room at the other
hospital because doctors there thought he might
have pneumonia.

But he did not appear to have pneumonia or any
other infection. He had no fever. His white
blood cell count was normal, and he wasn’t
coughing up sputum. His chest X-ray did show a
vague marking, but that was probably just fluid
in the lungs from heart failure.

I ordered the antibiotic stopped — but not in
time to prevent the patient from developing a
severe diarrheal infection called C. difficile
colitis, often caused by antibiotics. He became
dehydrated. His temperature spiked to alarming
levels. His white blood cell count almost
tripled. In the end, with different
antibiotics, the infection was brought under
control, but not before the patient had spent
almost two weeks in the hospital.

The case illustrates a problem all too common
in hospitals today: patients receiving
antibiotics without solid evidence of an
infection. And part of the blame lies with a
program meant to improve patient care.

The program is called pay for performance, P4P
for short. Employers and insurers, including
Medicare, have started about 100 such
initiatives across the country. The general
intent is to reward doctors for providing
better care.

For example, doctors receive bonuses if they
prescribe ACE inhibitor drugs to patients with
congestive heart failure. Hospitals get bonuses
if they administer antibiotics to pneumonia
patients in a timely manner.

On the surface, this seems like a good idea:
reward doctors and hospitals for quality, not
just quantity. But even as it gains momentum,
the initiative may be having untoward
consequences.

To get an inkling of the potential problems,
one simply has to look at another quality-
improvement program: surgical report cards. In
the early 1990s, report cards were issued on
surgeons performing coronary bypasses. The idea
was to improve the quality of cardiac surgery
by pointing out deficiencies in hospitals and
surgeons; those who did not measure up would be
forced to improve.

But studies showed a very different result. A
2003 report by researchers at Northwestern and
Stanford demonstrated there was a significant
amount of “cherry-picking” of patients in
states with mandatory report cards. In a survey
in New York State, 63 percent of cardiac
surgeons acknowledged that because of report
cards, they were accepting only relatively
healthy patients for heart bypass surgery.
Fifty-nine percent of cardiologists said it had
become harder to find a surgeon to operate on
their most severely ill patients.

Whenever you try to legislate professional
behavior, there are bound to be unintended
consequences. With surgical report cards,
surgeons’ numbers improved not only because of
better performance but also because dying
patients were not getting the operations they
needed. Pay for performance is likely to have
similar repercussions.

Consider the requirement from Medicare that
antibiotics be administered to a pneumonia
patient within six hours of arriving at the
hospital. The trouble is that doctors often
cannot diagnose pneumonia that quickly. You
have to talk to and examine a patient and wait
for blood tests, chest X-rays and so on.

Under P4P, there is pressure to treat even when
the diagnosis isn’t firm, as was the case with
my patient with heart failure. So more and more
antibiotics are being used in emergency rooms
today, despite all-too-evident dangers like
antibiotic-resistant bacteria and antibiotic-
associated infections.

I recently spoke with Dr. Charles Stimler, a
senior health care quality consultant, about
this problem. “We’re in a difficult situation,”
he said. “We’re introducing these things
without thinking, without looking at the
consequences. Doctors who wrote care guidelines
never expected them to become performance
measures.”

And the guidelines could have a chilling
effect. “What about hospitals that stray from
the guidelines in an effort to do even better?”
Dr. Stimler asked. “Should they be punished for
trying to innovate? Will they have to take a
hit financially until performance measures
catch up with current research?”

The incentives for physicians raise problems
too. Doctors are now being encouraged to
voluntarily report to Medicare on 16 quality
indicators, including prescribing aspirin and
beta blocker drugs to patients who have
suffered heart attacks and strict cholesterol
and blood pressure control for diabetics. Those
who perform well receive cash bonuses.

But what to do about complex patients with
multiple medical problems? Forty-eight percent
of Medicare beneficiaries over 65 have at least
three chronic conditions. Twenty-one percent
have five or more. P4P quality measures are
focused on acute illness. It isn’t at all clear
that they should be applied to elderly patients
with multiple disorders who may have trouble
keeping track of their medications.

With P4P doling out bonuses, many doctors have
expressed concern that they will feel pressured
to prescribe “mandated” drugs, even to elderly
patients who may not benefit, and to cherry-
pick patients who can comply with pay-for-
performance measures.

And which doctor should be held responsible for
meeting the quality guidelines? On average,
Medicare patients see two primary-care
physicians in any given year, and five
specialists working in four practices. Care is
widely dispersed, so it is difficult to assign
responsibility to one doctor. If a doctor
assumes responsibility for only a minority of
her patients, then there is little financial
incentive to participate in P4P. If she assumes
too much responsibility, she may be unfairly
blamed for any lapses in quality.

Nor is it clear that pay for performance will
actually result in better care, because it may
end up benefiting mainly those physicians who
already meet the guidelines. If they can
collect bonuses by maintaining the status quo,
what is the incentive to improve?

Doctors have seldom been rewarded for
excellence, at least not in any tangible way.
In medical school, there were tests, board
exams and lab practicals, but once you go into
clinical practice, these traditional measures
fall away. At first glance, pay for performance
would seem to remedy this problem. But first
its deep flaws must be addressed before patient
care is compromised in unexpected ways.

Sandeep Jauhar, a cardiologist on Long
Island, is the author of the memoir “Intern: A
Doctor’s Initiation.”


— Sandeep Jauhar
New York Times
2008-09-09


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