During medical school, I learned about randomized clinical trials. Every experimental drug went through three types of clinical trials before approval. There were Phase I clinical trials which tested for toxicity and dosing. Phase II trials then examined optimal dosing and efficacy. Finally, Phase III trials compared the efficacy of the new drug with the current "gold standard" treatment.
I'm now learning that health care policy doesn't always undergo the same kind of rigorous study.
I met up recently with a friend who is a primary care physician. His practice has just signed a contract with the state's largest insurer that reimburses not according to the traditional fee-for-service, which pays doctors a set price for each visit, test or procedure they do, but according to a newer standard known as "pay-for-performance." The insurance company will give his practice a budget for each patient; the doctors in the practice can earn more by cutting costs and by meeting certain quality goals, like controlling blood sugar or high blood pressure in patients.
I asked my friend if he was happy about the new contract.
"I guess so," he replied with some hesitation. "I'm not sure how else we are going to stop spiraling health care costs." But then he added, "I do worry about how this will affect my relationship with patients. If my patient comes in with a headache and wants a CAT scan, but I don't order it because I think it's not medically indicated, will that patient think I'm just trying to save money?"
I thought about his concerns, and at first could not see any downside to linking quality to financial incentives. When doctors are working on a fee-for-service plan, there's just not that much incentive for them to take time to promote healthy living or strong doctor-patient relationships; the payment system rewards for high turnover and pits doctors against the clock.
I knew that other industries, like business corporations and education, had successfully used pay-for-performance to improve quality. And health care quality, which is a secondary concern with fee-for-service incentives, could definitely use a boost. A 2003 New England Journal of Medicine study showed that only about half of patients received the standard, nationally recognized care for preventive health issues and acute and chronic conditions.
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