Wednesday, September 21, 2016

Medicare to Spread Toxic Pay for Performance to Your Doctor's Office

Because your doctor does not have a good job to do Medicare plans to rank/rate/grade physicians and "reward" them for clinical outcomes.    Alfie Kohn, author of Punished by Rewards wrote:

Recall the line of research finding that rewards tend to undermine the very things they’re used to promote. Remove the reward and there’s no longer any desire to continue performing the task. Assuming that we seek to nurture an attraction to the given activity (learning, painting, inventing, etc.), this evaporation of interest is disturbing enough in itself, but it also has the consequence of yielding poorer quality work in many instances, as scores of studies have confirmed.
The number of clinical parameters for each patient are conceptually endless and most of them are not truly under your doctor's control.  They are a product of individual genetics/biology and personal choices made over a lifetime.

Healthcare payment experts would be wise to revisit corporate executive behavior under stock option incentive compensation.  Executives backdated 30% of options to optimize their individual pay, at the expense of shareholders.  Extrinsic reward programs reduce the natural interest in performing a task, but they also cause people to take any method possible to garner the reward.  Ask 5,300 Wells Fargo workers.   

Prior Medicare efforts to reward healthcare organizations utilized a quartile ranking system, where over time "top performers" got a small percentage reward and "poor performers" or nonparticipants a deduction.  From year to year the pay for performance system was not predictive, i.e top performers one year did not stay in that category.  A system that is not predictive is not based on knowledge.  One failure of a theory requires its revision. 

Former Interim Medicare Chief Dr. Don Berwick called pay for performance at the individual level a toxic daisy chain.  That's exactly what Medicare is doing to your physician, if you are lucky enough to have one at the moment.  I'm sure a number of my physician friends will stop taking Medicare patients or simply retire.  Long ago they stopped taking Medicaid patients outside their ER call.

Our healthcare system relies on complexity and hoops seeming designed to deny or postpone needed care.  I predicted PPACA could not deliver on its promises to control healthcare costs.  America does not have a healthcare system.  It has a series of individual parts, with many concerned more about their bottom line than care delivery.

PPACA and the world's sick management culture have made most healthcare jobs difficult and at times distasteful.  They now want to enslave your doctor with financial handcuffs.  Doing something well and doing something for reward (or to avoid punishment) are clearly two different things.  Ask the folks at Wells Fargo. 

Update 11-25-16:  Add complexity to Medicare's convoluted P4P measures which are spreading like an Appalachian wildfire.  Also past performance is not predictive of future performance.  Ranking hospitals on a distribution for reward does not require knowledge.