An argument against paying for value

From JAMA Internal Medicine:

Physician organizations—under pressure to respond to growing costs—have increasingly asserted the profession’s responsibility to take a role in allocating resources, for example, by developing efficient practice guidelines and participating in the development of health policy. However, their policy statements have also consistently reaffirmed the primacy of physicians’ responsibilities to individual patients…

Recently, however, the concept of reimbursing physicians for “value” in health care has breached the wall. Value is defined as the health outcomes achieved per dollar spent—essentially, the ratio of quality to cost. Value has taken center stage in health policy deliberations and has become the basis for major changes in physician reimbursement, led by the Centers for Medicare and Medicaid Services (CMS). In 2015, CMS pay-for-performance programs for hospitals and for physicians will include measures of both quality and cost, and proposed legislation would incorporate value into the Medicare physician fee schedule. Private insurers are following the lead of the federal government, and health care organizations are passing the risk to their physicians with internal pay-for-performance programs that reward both quality performance and lower costs.

I’m truly conflicted here. Like any good “economist”, I’m worried about future health care spending. I know that fee-for-service just sucks, and that the financial incentives for practice are totally misaligned. But I remain totally skeptical about pay for performance (see this, this, this, this, this, this, and this). I don’t see much evidence that programs like that work, and I don’t believe that the things we can measure are necessarily the same as how we’d ideally define quality.

I’m also concerned with making doctors the ones responsible for deciding what’s “worth it”:

I talk a lot about the fact that we, as a society, need to think about cost-effectiveness if we are going to get a handle on the cost of health care. This means saying no to some treatments and tests, because we have to use health care resources responsibly. When I say such things, inevitably someone counters me by questioning whether I would feel the same way if my child’s life was on the line.

The answer is, of course not. If my child’s life were at stake, I would fight tooth and nail to get anything – and I mean anything – to save him or her. I’d do it even it it cost a fortune and might not work. That’s why I don’t think you should leave these kind of decisions up to the individual. Every single person feels the way I do about every single person they love, and no one will ever be able to say no. That’s human.

Similarly, I don’t think that it’s necessarily fair to make it a physician’s responsibility. I also want my child’s doctor to fight tooth and nail to get anything that might save my child. Many times, physicians have long-standing relationships with patients. Asking them to divorce themselves from the very human feelings that compel them to do anything that might help their patients is not something that I think will necessarily improve the practice of medicine. They also should be human.

So whose job is it? Well, mine for instance. That’s what I do as a health services researcher. That’s what policy makers should also do. That’s what we, as society should do. There are people who should have the responsibility of debating and deciding what is and is not cost-effective. They should have to make decisions that may be unpopular, and they should have to face the wrath of those whom the decisions impact.

But there’s no good way to make it an individual’s responsibility to determine what is cost-effective for their child. That hardly seems “ethical”. I’m not sure asking doctors to do it is such a good idea either.

I think Laura Goiten (who wrote the JAMA Internal Medicine piece) may agree with me:

[W]hen we put on our white coats and approach the bedside, we should put aside considerations of costs—and financial incentives to do more or less—and remember our professional commitment to our patients. Many parties stand to gain from changing patients care, and financial incentives are constantly shifting. The cost of a treatment or test in any given year is as capricious as whether an insurer covers it, or the duration of a patent—and as merciless as what the market will bear. In this unstable and economically driven environment, it is critical that the patient retains one—just one—financially disinterested advocate.

Someone has to care about value. Someone has to care about cost. I don’t think it’s realistic to think this person should be the one who needs care right now. I also don’t think it’s always realistic to think it should be his or her physician.


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