Sunday, July 26, 2009

Bad timing: NEJM: Obama’a top-down healthcare quality plan not working in UK

Bad timing: NEJM: Obama’a top-down healthcare quality plan not working in UK

The article is: Stephen M. Campbell, David Reeves, Evangelos Kontopantelis, Bonnie Sibbald, Martin Roland. Effects of Pay for Performance on the Quality of Primary Care in England. New England Journal of Medicine, volume 361, number 4, pages 368 to 378, July 23, 2009.

In UK, where they have had socialized health care for decades, the recent years have seen grand, extensive "pay-for-performance" plans. In a typical “P4P” plan, a doctor gets a bonu$ from the govt if he or she delivers certain clinical activities with patients, if that activity is warranted. An example would be: do you get all women over the age of 40 to have a mammogram every other year? Do you get all men in a certain age range to have colonoscopy as recommended? Do you ask each and every patient whether they smoke?

England has integrated a lengthy list of these incentives into their physician pay scheme in order to achieve great quality and manage costs. The whole concept is that if illnesses can be prevented or detected early, costs to treat those illnesses will be decreased. Remember: all the docs work for the govt, and he who has the gold makes the rules. So, the govt gets to decide how to pay docs, and by incentives, directs what the docs will do.

This current NEJM study does not achieve the optimal goal of connecting the incentives to the desired long-term outcomes. For the mammogram example, the long-term outcome would be the early, versus late, detection of breast cancer, AND prompt treatment once detected. The outcome would be: lower five-year mortality rates from breast cancer.

This study has more easily measured outcomes: does the P4P incentives actually end up driving docs to perform the desired behaviors? The results show that, yes, to some degree. But, it seems that the docs improve to some degree, then top out before reaching 100% compliance. Plus, the docs may increase these activities but at the same time do less of other things they should be doing. AS this study notes has happened for cardiovascular care.

It only makes sense. A doc can only do so much in a given span of time. Something has to “give.” The law of unintended consequences is operating.

This is where we in the U.S. are headed if we put a community organizer and his friends in charge of how docs get paid. Obamedicine. When you incentivize something, something else somewhere else will be compromised. To get optimal medical care, you would have to pay a “bonu$” for each and every little thing under the sun that the doc should do.

Never mind what you the patient actually went to the doc toge thelp with. You will be spending your visit answering a big range of questions and going through a range of screening activities each vist, so the docs can piecemeal their salary together.

People note that a big difference between the U.S. healthcare system and other healthcare systems is the “overhead:” paperwork, claims certification, etc. Sure, it would be great to see a system where the capitalist system is subverted and paperwork costs are dropped. But this NEJM study, exposing the weak results from UK’s experience, suggests how much micro-management, bureaucracy, documentation, and paperwork would be needed to adjust docs to perform “optimal” behavior.

Upon scanning this article, I don’t see how such extensive oversight will yield the suggested savings. My guess is that we will have an equal or geater level of "overhead."

We need to use this evidence as it comes out of UK’s extensive years of top-down management before we decide if we want to adopt their plan. For that reason, this NEJM article is very valuable and needs to be digested well.

So, let's take some time before we vote for this 1,000+ page health care reform plan that no one has yet read. [BTW: FWIW: I heard, to be "green," it was printed on the flip-side of the sheets of paper used to print the 1,000+ page TARP.]

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