Be a good doctor-win valuable prizes!

August 15, 2005

Do you remember when you applied to medical school because you thought it would be a great way to help your fellow human beings, and when being a good physician was its own reward? Times have changed, and now doing your utmost to help your patients is not just a sacred trust, but a way to get paid better!

Do you remember when you applied to medical school because you thought it would be a great way to help your fellow human beings, and when being a good physician was its own reward? Times have changed, and now doing your utmost to help your patients is not just a sacred trust, but a way to get paid better!

I am being somewhat facetious, of course, because the "pay for performance" initiative1 actually makes some sense to me, at least in theory. In general, the higher the quality of a good or service, the more we pay for it. If some doctors provide a higher level of service, and keep their patients healthier, doesn't it make sense to compensate them for the extra time/cost/effort/knowledge required to do this? Other physicians who provide less service, or don't keep their patients as healthy, logically can be rewarded with relatively fewer dollars.

Noncompliance

Consider the issue of noncompliance. Noncompliance is common; roughly half of Americans don't follow physician orders or take medicines as prescribed. Noncompliance leads to 23% of nursing-home admissions, 10% of hospital admissions, and 125,000 deaths annually from cardiovascular disease. A recent article reviewing this topic even describes a physician who was sued (unsuccessfully) by the family of a patient who died as the result of noncompliance.2

It is also a major issue in eye disease. Harry Quigley, MD, professor of ophthalmology and chief of the Glaucoma Service at The Wilmer Eye Institute, Baltimore, has shown that noncompliance among patients with glaucoma is common, with as many as 70% of patients not exhibiting full compliance with follow-up visits and therapy.

A report from Johns Hopkins University School of Medicine and a disease management company called American Healthways Inc., generated by a panel of 250 physicians and medical managers, suggests that pay-for-performance plans, to be equitable, need to take into account the patient side of the equation.3

If certain physicians, for any number of reasons, attract sicker or less-compliant patients, those physicians may appear to providing lower-quality care when they are not. If certain patient populations are less compliant with medical care, the physicians who care for them would presumably be punished.

Possibly, physicians would have an incentive to select out those patients whose condition is easiest to manage and who are most compliant. The report asks that consideration be given to rewarding the patient, not just the physician, for success.

Who is responsible?

Who should take the hit if a patient does poorly as a result of noncompliance?

Charles Booras, MD, practicing in Florida, reports being given a poor review by an insurance company because a noncompliant 38-year-old diabetic patient of his is in poor health. According to Dr. Booras: "Noncompliant patients are going to get kicked out of some practices . . . . It just isn't on the radar yet for insurance companies to try to make the patients more accountable for their own outcomes."2

Suppose payers punished glaucoma specialists because so many of their patients do not comply with therapy. Would we discourage young ophthalmologists from that career path?

My belief is that pay-for-performance makes very good sense in theory. But putting it into practice-considering the impact of variables such as noncompliance and the importance of patient behavior in general-may represent quite a challenge.

Peter J. McDonnell, MD is director of The Wilmer Eye Institute, The Johns Hopkins University School of Medicine, Baltimore, and chief medical editor of Ophthalmology Times. He can be reached at 727 Maumenee Building, 600 North Wolfe St., Baltimore, MD 21287-9278. Phone: 443/287-1511 Fax: 443/287-1514 E-mail: pmcdonn1@jhmi.edu

References

1. Medicare mulls incentive program. Ophthalmology Times 2005;5:1,10.

2. Patients ignore doctors orders. The Wall Street Journal March 9, 2005.

3. Johns Hopkins-American Healthways 4th Annual Physicians Meeting and Outcomes Summit. http://www.rewardingquality.com/.