Value Added Medicine?: Movement on Doctor's Compensation Comes to NYS

Teachers are under attack. A major tool is the evaluation system, which improperly relies heavily on commercialized standardized test results. The test results do not take into account what some economists call externalities, factors external to the immediate teaching process? Is the student prepared? Does he or she attend class regularly and with attentiveness? Is the school tone, set by school administration, problematic? Has the administrator assigned the teacher a group of students with more challenged circumstances than students in other classes in the school? Does poverty impact on the student's life?

Despite the illogic of holding test results central to teachers' performance, this method is being steamrolled through, by policy makers, test-promoters and media pundits.

In New York State, outcome-based evaluations are being used to evaluate doctors. Doctors will be rated according to the patient's outcome after he or she leaves her or his office. The same poverty concerns enter into consideration. Does the patient live in a high pollution area? Does the patient's job have high stress? Does the patient experience classism, racism, sexism or homophobia? Does police frisking create stress in the individual's life? Are there affordable fruits and vegetables available in a supermarket in easy access to the patient's home? Are there affordable gym facilities available to the patient? Then, there are the lifestyle issues? Does the patient floss her or his teeth? Does the patient have a preference for a healthier diet? Does the patient exercise? Does the patient take recreational drugs or smoke? Does the patient bicycle without a helmet or reflective gear?

Is all of this the doctor's responsibility? Will doctors be responsible for the effects that externalities play upon the patient's life? Will the doctors avoid working with high-poverty clients? Will doctors find it incumbent to their income to push aside patients that neglect to handle his or her life with proper life-style choices?

The New York Times yesterday opened its front page story, "New York City Ties Doctors’ Income to Quality of Care," on the topic with:

In a bold experiment in performance pay, complaints from patients at New York City’s public hospitals and other measures of their care — like how long before they are discharged and how they fare afterward — will be reflected in doctors’ paychecks under a plan being negotiated by the physicians and their hospitals.

The proposal represents a broad national push away from the traditional model of rewarding doctors for the volume of services they order, a system that has been criticized for promoting unnecessary treatment. In the wake of changes laid out in the Affordable Care Act, public and private hospitals are already preparing to have their income tied partly to patient outcomes and cost containment, but the city’s plan extends that financial incentive to the front line, the doctors directly responsible for treatment. It also shows how the new law could change longstanding relationships, giving more power to some of the poorest and most vulnerable patients over doctors who run their care.

The article closed with quotes from various doctors citing the difficulties with the approach. Indeed, Dr. David Himmelstein, professor at the City University of New York and a visiting professor at Harvard Medical School noted, “The consequences in a complex system like a hospital for giving an incentive for one little piece of behavior are virtually impossible to foresee.”

But Dr. Himmelstein said there were still hazards in the city’s plan. He said that when primary-care doctors in England were offered bonuses based on quality measures, they met virtually all of them in the first year, suggesting either that quality improved or — the more likely explanation, in his view — “they learned very quickly to teach to the test.”

“I think the most interesting finding is, things that were not measured, in a few studies, appeared to have gotten a bit worse,” Dr. Himmelstein said. For instance, patients were not as likely to stick with the same doctor, possibly because they were encouraged to see whichever doctor was available — speed was one quality measure — rather than the doctor who might know them best. In another example, while the doctors reported that they had controlled blood pressure in virtually all their patients, a random survey showed no downward trend in blood pressure or strokes.

There could have been any number of ways of outsmarting the system, he said: “If you take blood pressures three times and report the lowest, is that lying or merely tipping the numbers in your favor?”

Dr. Himmelstein also said doctors could try to avoid the sickest and poorest patients, who tend to have the worst outcomes and be the least satisfied. But physicians within the public hospital system have little ability to choose their patients, Mr. Aviles said. He added that he did not expect the doctors to act so cynically because, “in the main, physicians are here because they are attracted to that very mission of serving everybody equally.”