Monday, January 14, 2013

Proposed New NYC Medical Payments

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.

In 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.

One 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.

Of 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".

Yes, I've 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 done well.

But 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.

There's 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.

My big concern is that proposed payment "reforms"
will not accomplish its stated goals, but will create far more unintended consequences than its proponents realize.