New York Times: "New York City Ties Doctors' Income to Quality of Care" (1/11/2013).
Another possible headline: "Government bureaucrats and doctors' union negotiate over pay incentives to reward/punish doctors for practicing a certain way in NYC public hospitals".
Welcome to the future.
principle, paying for performance is fine. But when metrics are chosen
badly (or because they're easy to measure even when they have little
bearing on actual quality of care), then you're setting the stage for
all manner of unintended consequences.
example are rules to pay/not-pay based on whether patients develop a
certain type of catheter-related urine infection. These rules have
resulted in switching to different protocols that reduce that particular type of
infection, but can cause more patient pain (which isn't measured) and
elevates the risk of different kinds of bladder infection and/or injury.
course, this isn't a problem limited to medicine. Nor is it solely a
problem of government (vs. badly run private bureaucratic organizations).
But far too many of the proposed "quality
measures" I've seen are the equivalent of "security theater".
definitely seen many cases of quackery and bad medical practice. But the
response by too many policy-makers has been to advocate purportedly "objective" or "evidence based" protocols, which many doctors criticize as being too rigid or
"cookbook medicine". Bad doctors can
inappropriately use their medical autonomy unwisely. But the solution
is not blunt tools that reduce medical autonomy across the board.
On a personal note, my wife Diana
has some thyroid problems and she's an outlier on how she responds to
certain treatments. If she were treated according to the standard
protocols, she'd be in constant misery. Fortunately, she was able to
find a physician specializing in her type of problem and is willing to
judiciously stray outside the standard guidelines. As a result, she has
in many of the new payment models, this treatment course would be
presumed to be bad medicine, even though it is completely appropriate
for the small but non-trivial segment of the population that doesn't
respond well to the standard therapy.
room for constructive debate on incentive structures and their effect on medical
quality. I've practiced in academia (as a salaried university medical
school professor), in a large HMO (Health Maintenance Organization)
where doctors were paid on a "capitated" basis, and in traditional
fee-for-service private practice. All of those systems have pluses and
minuses, and all of those systems can create good incentives as well as
perverse incentives to "game" the system.
big concern is that proposed payment "reforms" will not accomplish its stated goals, but will create far more unintended consequences than its proponents realize.