insurance, medicine, primary care

The Problem with Pay-for-Performance

United Health Care has announced that they will be changing how they pay physicians, according to this article.  Currently, most payment is based on what is call a “fee-for-service” plan.  In other words, a doctor does something and bills for it.  There are problems inherent in this system- the main one is that it encourages over-utilization of services.  The doctor has an incentive to perform more services, because that’s how he or she gets paid.

United wants to start paying for “quality of care,” or “pay for performance.”  On the surface, this sounds great, right?  After all, why should a doctor get paid for a bad outcome?

Here’s the problem- people are not widgets.  You can’t plug them into an assembly line and have them all come out the same.  People have individual needs and wants.  They have their own priorities.  They have their own beliefs about health care.

I have many patients who don’t adhere to my treatment plan.  It’s for various reasons.  Sometimes it’s the cost of medications.  For others, side effects are intolerable.  Some have so many family stressors that it’s all they can do to see me once a year, let alone follow all of my directions. Some just don’t seem to care.  Some have a disease process that is so bad that no matter what I do or they do, nothing is going to get better.

In many cases, I don’t follow treatment guidelines.  For example, the patient with severe Alzheimer’s disease, diabetes, and high cholesterol.  Guidelines say they should have a well-controlled blood sugar, be on a statin for cholesterol, and be on an ACE inhibitor to preserve renal function.  Common sense says that the patient is at the end of their life and none of these medications are necessary. 

Here’s what I foresee happening with pay-for-performance.  “Non-compliant” patients will be discharged from practices.  “Compliant” people whose disease is difficult to control will be discharged.  People will be on more medications than they really need, simply to meet an incentive goal. 

Here’s the thing- insurance companies would love it if 1+1=2 all the time.  However, in medicine, that’s not how it works.  Medicine is an art, and everyone needs to be treated as an individual.  Because we’re humans, not robots, this type of plan is doomed to failure.

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