Should physicians get paid for quality improvement?

OB/GYN News, Dec 15, 2003 by Gail M. Amundson, David Himmelstein

YES At HealthPartners we have been supplying medical groups with comparative performance data for 11 years, but it's only been since 1997, when we introduced bonuses tied to quality, that we've seen rapid improvement.

As the associate medical director for quality at a health plan, I structure the incentives for medical groups within our plan. The focus is to ensure that the medical groups change their systems to produce quality care without variation.

The only way to get there is by creating an infrastructure based on the best evidence. We've created a bonus system for medical groups that meet our clinical targets. The key is that bonus pools themselves need to be big enough so that it's difficult to ignore them. Our bonuses usually range between $90,000 and $250,000 per medical group.

And the targets we measure must be realistic. We usually choose a limited number of criteria to get the whole network focused on the same aspect of quality improvement.

We choose the targets using our comparative quality report on all of our medical groups. The Clinical Indicators Report includes measures on clinical topics such as behavioral health, heart disease care, diabetes care, preventive care, healthy lifestyle counseling, and treating tobacco addiction. We look at the previous performance in these important areas and set the goals to be achieved.

This is having a significant impact on the behavior of clinicians within our medical groups. We hear directly from medical groups in our plan that they wouldn't be able to focus on quality improvement measures without the bonuses.

There simply wouldn't be an imperative to make the changes otherwise. You have to have someone focused on quality improvement who works on forms, staffing, and getting feedback from patients. The bonus program doesn't pay for all those activities but it does provide enough of an incentive to shift the focus onto quality.

Paying for performance isn't without pitfalls. If you run an incentive program at an individual provider level the decision to accept a sicker patient could lessen a physician's chance of a bonus. That's why our bonus program focuses at the medical group level, where work on achieving quality focuses on system changes.

We hear about the success of our incentive program straight from medical directors in our network. They tell us the greatest value of the incentive program is the focus it puts on creating systems that make quality health care not just the fight choice, but the easy choice.

Dr. Gail M. Amundson is associate medical director for quality at HealthPartners in Minneapolis.

NO Policy makers are likely to do more harm than good when they offer doctors financial incentives based on quality measures.

The overall quality of a primary care physician's work is difficult, even impossible, to measure accurately. The quality measures we use assess a narrow range of easily quantifiable activities. They are, at best, incomplete indicators of quality care.

This narrow focus risks distracting physicians from the many aspects of care that are not measured, which in many cases are more important. For example, it's easy to ascertain from billing or lab records whether doctors are checking their patients' cholesterol levels, and most financial incentive programs include some reward based on ordering such tests. But it's almost impossible to tell if doctors are doing a good job counseling patients about diet, exercise, and smoking, which is probably more important than a lab test.

So financial incentives reward the easily measurable but less important activity. Implicitly, doctors are told to forget about the most important ones.

And these financial incentives supposedly based on quality encourage doctors to cheat. We've seen it happen in the business world. Executives who got big bonuses if their companies were profitable routinely cooked the books. Think of Enron, HealthSouth, Global Crossing, and many others.

In the case of health care, doctors create the very data used to measure our outcomes. When our practices are assessed based on these data, the data will have all the accuracy of a tax return.

For instance, an unscrupulous doctor paid extra for controlling diabetic patients' hemoglobin [A.sub.1c] levels could obtain fasting glucoses from patients who were not really fasting. This would falsely label some patients diabetic whose hemoglobin [A.sub.1c] levels would be easily controlled.

Paying doctors for good outcomes also creates incentives to dump the sickest patients and those who do not comply with their advice. Should doctors be penalized when they care for an elderly woman who refuses a Pap smear or a man who declines sigmoidoscopy?

Finally, most of the things we are proudest of we don't do for money. Doctoring is fundamentally about human relationships, about trying to help another human being. When we reduce that to a series of tasks that we're paid to perform and others that we're not paid for, we risk losing the very essence of our profession. We risk making patients into commodities and substituting money for morals.