Doctors, Quality of Care, and Pay for Performance
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- เผยแพร่เมื่อ 5 ต.ค. 2014
- "Pay for performance" is one of those slogans that seem to upset no one. But as with so many things in health care, it's much more complicated than it appears at first glance. Watch and learn!
This episode was adapted from a NYT piece Aaron wrote for The Upshot. All references can be found in links there: www.nytimes.com/2014/07/29/ups...
John Green -- Executive Producer
Stan Muller -- Director, Producer
Aaron Carroll -- Writer
Mark Olsen -- Graphics
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/ realjohngreen
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I work in education, another area where pay for performance has been proposed. In education, at least (and I suspect in health care as well), these seem short-sighted because they are based around a perception that if teachers only *tried harder*, educational outcomes would improve. However any difference in how hard teachers are trying is swamped by factors such as their working conditions (eg number of classes taught or number of students per class), the resources available (everything from copier paper to special ed referrals), etc. We might get small improvements by adding incentives, but they are a drop in the bucket when we look at disparate outcomes.
The same phenomenon might occur in health care. Instead of paying for performance, improve the amount of time spent with each patient (by paying them more to spend more time with the patient), or ensuring they have quality of life considerations such as time off. I don't know if it has been researched, but that might be a key to more substantial improvements.
So in a pay for performance system, if doctors try harder to get better outcomes, then they'll be rewarded. This implies that doctors are currently not doing their best for their patients. I think that's why there were no real differences between both models. Perhaps doctors now are already doing the best they can? (with their particular training, facilities, etc.) Now that doesn't include every doctor out there, as there are always people outside the mean, but as a whole it might add to reason why pay for performance doesn't appear to produce improved results.
Yup I think that doctors are already strained and working hard jobs. P for P could end to doctors getting burnt out or even worse outcomes. I am not arging every doc is perfect just that doctors dont want to work harder for often good reasons.
This is just superb, I've been looking for "health & wellness coach salary" for a while now, and I think this has helped. Have you heard people talk about - Leyackenzor Dumbstruck Leverage - (should be on google have a look )?
It is an awesome one off guide for discovering how to learn an effective Ho'oponopono technique and achieve the life you deserve minus the headache. Ive heard some incredible things about it and my work buddy got great success with it.
Want to improve it, just look at the stud the VA in Missouri did several years ago. At the time they were spending upwards of $45K per year per patient to care for disabled veterans. They decided they had to do something, so they got the bright idea to send the doctors out into the field. Two things came out of this study - the cost dropped to $17K per year per patient. Some of the physicians said that it was because they could head off pneumonia in quadriplegics etc. and that they got to KNOW their patients. Imagine that. House calls. Who knew?
It has been said "hospitals are for the doctor's convenience, not the patient's" I don't remember who by though...
This was a great overview of FFS v. PFP and I'd love to see a follow up on the effects of salaried/employed physicians and capitated payment models on the quality of patient care. Thanks for the awesome videos! Keep 'em coming!
All of these issues and results translate directly to the recent failures of education policy in the US. Dr. Carroll hinted at that. People always want to hold individuals responsible for outcomes, when the systems of our society are what is truly responsible, not what one person can or can't do in the face of a tsunami. These issues also translate to patients themselves, being held to account (increasingly literally by their employers) for failing to personally overcome effects that are out of their control.
Well done summary! Very balanced point of view. All good points. I recall recently hearing that a physician who was on one of the recommendation comities for measurable quality scores ended up having major ties to a pharmaceutical company. The government and AHRQ had to review nearly all of the recommendations due having to call into question the medical validity of there original recommendations. QUALITY...
The problem that I have seen with a lot of 'pay for performance' plans in previous jobs that I've had is that they favor 'exceptional' performance over consistently good performance. This might seem like a good idea, but when you consider that only 5-10% of your staff may fit into this model at any given time, most of the people lose out. Further, I have seen many situations where the base pay for a position is artificially lowered below market standard so that the person has to 'work harder' to get their incentive pay for performance. Then the bar for performance is pulled higher and higher until many people are excluded.
This creates anxiety, disturbs the ethical balance between doing right and doing what's profitable, and it can turn even the most simple business into a disaster. (The banking industry is an example of where this fails.) When mixed with lives and deaths of patients, I can only imagine that it would be far worse. Additionally, a patient's health improvement is often reliant on their ownership of the issue and how well they follow the guidance of the doctor. If a person is obese, a smoker, and heavy drinker; the doctor can advise the patient to lose weight, stop smoking and drinking, but those issues may persist. At that point it is not 'bad care' that contributes to worsened results, but a lack of patient engagement on the issue.
The question is whether you focus on the mitigation of negatives or the propagation of positives as the means to incentivize the process. Is it that you want to stem growth of hospital borne infections, accidents in operating rooms (such as improper surgeries being performed), etc. I think that one thing that would be helpful is to provide and incentive to doctors to minimize chemical interactions with patients. (Fewer drugs with a greater impact on improvement of health and quality of life.)
I have seen points where someone is prescribed a drug for an issue that is inherently a lifestyle problem (or not even a legitimate medical issue), only to get another drug to attack an issue caused by the first drug. Then later their decline leads to further treatments and drug therapies, until such a time as they either die, or seek alternative options. (Such as better diet, exercise, and preventative lifestyle choices.) Doctors also need to be more engaged with their patients' situations. My father was permanently disabled by a doctor that failed to change dosing applicable to weight-loss, as per instructions of the medication, leading to severe toxicity. (He lost over 60lbs during treatment, but the prescribed concentration was never changed.)
i would suggest the the ending comment was the exact point. if different additions to the "pot" result in the same basic outcome, then its the physicians own "values" that drive the results.
I think it is a great idea and we need to allow more time to fully understand what works and not. I truly enjoyed Harvard Business Review which actually shares great examples of its successful implementation.
First off, I would like to commend Health Triage for providing such an informative video that addressed the benefits and concerns of pay for performance. A large majority of jobs in the United States have benefited from pay for performance incentives and have much more explicit criteria to meeting those “quality” benchmarks. That is where the issue falls when trying to attach a quality measurement to healthcare; what merits quality? Is it the number of patients a doctor has walk through their door or the amount of prescriptions a doctor writes? Or is it how many years their patients live and the number of deaths experienced under a certain doctors watch? Many arguments related to this video have fallen into the issue of money and whether doctors should be obligated to help or bribed with financial incentives. Though I cannot speak for all doctors, I would venture to say that the majority of doctors today want to improve the lives of the patients they see. The problem with pay for performance lies within the measure of quality care provided. A study published in the National Library of Medicine found that the vast majority of doctors being graded on quality did not have adequate numbers of quality events measured to even support the findings. Publicizing such inadequate studies could be detrimental. Doctors should be financially compensated in a way that allows them to be driven by a desire to improve the quality care given to each and every patient they encounter. In order to improve this quality we must measure it, and in order to measure it we must be able to clearly define it. If we simply define quality as number of patients seen, doctors will push for quantity over quality. If its defined by prescriptions written, doctors will be influenced by pressuring pharmaceutical companies to resort to prescription drugs when not necessarily needed. And if we define quality as years lived or mortalities seen, doctors will refrain from seeing the poor, the needy, and the severely injured or sick. The measure of quality is necessary but, if done incorrectly, will deter from true quality of care.
I'd love it if you could do a video discussing nurse practitioners and physician assistants and quality of care as compared to physicians!
Your conclusion hit the nail on the head. We are carbon-based units with quirky operational systems. When beancounters attempt to quantify healthcare,albeit for good reasons, they invariably set off unexpected outcomes which seriously undermine patient care. At heart, most of us are beancounters until we are admitted into ER.
Healthcare Triage
Aaron, would you mind doing an episode on either of the following topics:
-Veganism/Vegetarianism
-Circumcision
Myths about circumcision do need to come into light, there are no good reasons to use circumcision
Disease: with a condom, either was has same statistics
Masterbation stopping: it doesn't stop anyone
Religion: your choice, but don't push it onto others
Aesthetics: social norms change constantly anyway, but penises are all pretty weird, right?
Propaganda and social norms are no reason to cut off a functioning, and useful foreskin
This was an extremely well referenced report on the difficulty of defining quality, and how sometimes the goals picked for “pay for performance” are not directly an indication of the quality of performance. Otherwise, why wouldn’t we just have some of the tasks appointed to a computer with AI and a “ clerk” to dispense the print out?
I'm really interested in interning on Healthcare Triage next summer. Anyone know how/if I can make this happen?
What about Accountable Care Organizations. From general descriptions it seems like ACOs are a movement toward across the board enforcement of pay for performance standards; am I wrong to assume this? Also, what are you thoughts on ACOs and is there any current data on efficacy or projected efficacy? Thanks!
A pay for performance model, in theory, is an excellent idea. Merit-based evaluation for healthcare professionals that aims to track performance and then compensate providers fairly based on health outcomes is an exciting prospect. I am a proponent for this initiative in regards to the idea that it would lead to increased evidence-based practices and hopefully reduce variation across health care with the aim of increased diligence to safe practice measures. However, there are some conflicting concepts to consider.
First, a physician is bound to practice in a patient's best interest, reducing harm and doing good, while at the same time respecting a patient's autonomy. Sometimes these tenets are paradoxical. Although a physician is aware of best practice measures such as implementing drug regiments or following treatment protocols, if a patient refuses these health recommendations then the provider must respect the patient's wishes. In these instances, a patient's autonomy may interfere with optimal outcomes and, unfairly, would reflect poorly on a provider's level of care or duty to their patient. Another concern I have is a drive towards hospital-based protocols, limiting physician's clinical judgements and often times subjecting patients to increased testing (costs). Although this may sound like fee-for-service, I believe in a pay-for-performance system, administration may hope to cover "all their bases" and over-evaluate patients in the hope of catching "red herrings" and reducing negative outcomes. With these considered, I believe that pay for performance system, like most merit-based evaluations, is a good idea in theory, but cannot be implemented without consideration of extenuating circumstances or variables affecting positive patient outcomes.
Exactly, one major problem with pay for performance is that it creates a disincentive for health care providers to practice in poor and disadvantaged areas where patients will inevitably have poorer health outcomes.
It is naive to think the pay for performance will change the way physicians practice. However, it is still immensely important.
Most physicians do not practice based upon how they are paid. Most practice based on how they were taught and what they learn through continuing education and experience. Most doctors only have a rudimentary understanding of how money flows through the system and are not interested in deepening their understanding.
Pay for performance is still vital though because it can change the way resources are allocated at a higher level. For example, large systems pay a lot of attention to the source of their revenue. If more money is coming in for quality/prevention, they will allocate more resources (capital, personnel, executive attention) to those projects. If a systems receives an increasing amount of money tied to quality metrics for a population of high risk diabetics, it might create new diabetes education sessions or look at options for increasing the participation/effectiveness of its existing diabetes interventions. Without quality driven payment methodologies, systems allocate resources towards current money making areas such as filling hospital beds, expanding the use of highly reimbursed cutting edge technologies, and attracting high revenue producing surgical specialties/cases.
The idea of pay for performance has long term merit not in affecting the way individual physicians practice, but in changing the way large providers prioritize projects.
would like to see a healthcare triage video about the alternative medicine hypothesis of "leaky gut" in relation to other health and mental health symptoms.
The pay for performance idea can lead to many different things, both positive and negative outcomes. While paying a healthcare provider extra money when they provide excellent care or help treat a specific number of patients is a good thing in retrospect. But with this comes many issues. There are people out there that would take advantage of this system by possibly lowering their standards and the level of care patients want and need just to treat more patients for more money. This is where things get hairy. Utilitarians would not care much about the act (administering the best care possible) as long as the outcome (more money based on the "pay for performance" idea) was beneficial or positive for them. In the video he mentions a few studies that showed that "pay for performance" did not work in extended or larger group sizes. It was only successful in a very small sample size for a short period of time, then the performance was the same as the non-pay for performance groups. This tells me that "pay for performance" is not a good thing in the end, although in conception and in small scale projects it does work in a positive manner. In the future someone may be able to come up with a new version of this "pay for performance" that improves the current health care world greatly. But until then we shouldn't "pay for performance" until there are larger studies and better results.
Hypopnea in infants (and possibly SIDS) caused by Dtap? I know its random but i have seen it pop up a lot lately. I have done some research but the internet only scared me more and I had to stop looking. Please give me some insight.
This is tremendously concerning regarding the ACA, because my question has always been "how will the ACA reduce total national spending?" The answer always comes back to various provisions in the law written for performance based compensation for hospitals. However, this is much more complicated than anything addressed in the video. As I understand it, certain groups of people with specific illnesses will be assigned to some service provider, and then that sets the baseline from which they can then improve. This would give better statistical control than a blunt pay for performance method. I truly hope it helps.
Because if the ACA doesn't do anything to reduce total cost growth, we're all screwed. That was the problem to begin with. Yes, lack of insurance is bad, but it never threatened total implosion of our economy due to a health care sector that grows out of control. Then knock-off effects propagate everywhere. People can't get jobs because health care benefits are too expensive for employers to pay for, and so on. Subsidies (one part of the ACA) will not reduce cost growth. It will increase it.
Without articulate mechanisms to reduce cost growth, we are doomed. I mean that seriously. Our civil society will not survive the demographic transition.
I know a guy working for an insurance company--they're starting up (as I understand it) a pay for performance program for chronic diseases.
in mexico we got somethig similar but it's more simple... get you goals or get fired, oh and the goals are stupid high, like performing 100 baciloscopies (true to be told you only take the sample and fix it un alcohol) in a town of 400 people ...
Can you do a video on Soylent please?
Could you do an episode on vitamin C? With flue/cold season starting up I am already at my limit with people who think vitamin C will cure all of their problems, and refuse to go to a doctor untill they need to be hospitalised.
i think there is something about vit C in one of their Q&A vids but im not sure
Yeah, they covered multivitamins in their questions video. They're useless unless you have a real deficiency. sciencebasedmedicine.com has some nice articles on Vitamin C and the flu as well.
I think doctors can only do so much. When a patient refuses to exercise or diet correctly, or to take their medications as prescribed, what is a physician to do????
Prescribe hourly enemas with chunky peanut butter and tabasco. Patients find another doctor. Problem solved.
EXACTLY! Yes, doctors should advise their patients on how to live a more healthful lifestyle, but they should not have to hold the hands of self-thinking adults. Admittedly, I am ignoring some cultural and economic influences with this statement, but it is ultimately up to the patient to be responsible for his/her own health.
Overall great video/article. My one major issue is with the part where you say "...hospitals in resource-starved settings, caring for the poor, might be penalized because what we measure is out of their hands. A panel...recommended that the Department of Health and Human Services change the program to acknowledge the flaw. To date, it hasn’t agreed to do so."
While this is true, it's a more complicated story; adjusting for socioeconomic status would essentially excuse a lower quality of care for the poor. Either side of the coin has problems, but this is a very complex issue in developing quality measures and it's a shame to only see one side addressed in an otherwise balanced summary.
I think a big problem with pay for performance is something that the doctors have absolutely no control over: their patients. Doctors can prescribe needed medications, recommend diet and exercise changes, and do all sorts of things, but if the patient is noncompliant, it does absolutely nothing. What's the point in prescribing a blood pressure medication if the patient doesn't take it correctly or at all? It's not fair to doctors to completely base their payment on outcomes when part of the effectiveness of a therapy is due to patient compliance.
What happened to all of the gumballs inside the pill capsule in the background?
oh, that's why it looked odd, thanks
There needs to be a good leader in all office encouraging good outcomes and asking questions. They need to get 'buy in' from the office MDs before starting this though.
Pay for performance is something that I personally do not support (and as a teacher, it's always thrown around that we should have that too). I think, like Aaron says, it's too hard to actually implement and create change, and what do you decide measure? Which parts to you weigh with more importance?
Maybe it's a good idea in theory.... but it's way too hard to actually implement effectively!
I think that pay for performance seems like a logical idea. If doctors are expected to get rewarded based on good outcomes they are more likely to work harder towards those goal, which in turns means better outcomes for their patients. The only thing I find slightly off-putting is why do doctors need that incentive? It's their job to help their patients and that should be all the incentive they need to put all their efforts into their job. It could also be unfair in a way because even if a doctor works hard the treatment may not help their patient which leads to a bad outcome. This can affect their pay and credibility without people knowing the full story. I still think that it is a good idea because it means that doctors will continue to work harder and learn new techniques to help their patients reach a good outcome.
can you tell us about electromagnetic fields and its effects on the human body? i am refering here to things like phones ,tablets, wi-fi, etc. have there been any conclusive studies about it ?i saw thingy that electromagnetic fields in phones could be the cause for the rise in brain cancer in teenagers in australia by about 20% in the last decade . if anyone has any info about this topic i would appreciate it :)
Absolutely none and, if you are unaware, the electromagnetic fields doing as such is one of the very out there pseudoscience claims like chemtrails.
_"rise in brain cancer in teenagers in australia by about 20% in the last decade"_
Briefly looking at Australian Cancer Database figures, it doesn't seem to suggest anything of the sort. Where are these numbers pulled from?
Additionally, prevalence of brain cancer among teenagers is generally pretty low. Even assuming 20%, given the small numbers and statistical fluctuations it might not be significant at all.
Is there evidence that some foods are better raw or cooked nutritionally?
That depends on which nutrient you want. Cooking destroys some, while increasing the bioavailability of others.
Then why do students get paid more from my ppo and medicare than my private general doctor?
this is what happens once you bring the market in healthcare. medical providers are going to inflate prices to attractive more investors. and usually they deliberately overspend just to make sure you have the appearance of good quality care most sometimes it's not usually the case.
Healthcare Triage Is the pill canister in the background empty now? I seem to remember it being full in the past.
Pay for performance sounds like a great way to get providers to stop caring for really sick patients.
I hate how in most of these videos, even the old ones, there are no links at the end to the previous and next videos. Why even bother putting the names of the videos there if you're not going to link them?
I feel like you're biased. I like the idea of pay for performance. And everything you listed was a improvement but you found a way to blow it off every time
I feel like based on these results is that we may be at maxiumum potential as far as health care goes. If you can't bribe someone to do it better, and you can't punish them to do it better, it may be as good as it gets.
Reduce paperwork perhaps?
video needs captions!
I’m not sure the 2012, 30 day mortality study is completely valid as a means of measuring outcome. Mortality has a large variable pool, and death isn’t he only indicator of deceased “illness” - which matters.
Hello World!
Why aren't we asking the caregivers how to improve care, instead of ruling from on high? Moreover, why are we still using carrots and sticks? It's detrimental unless the task is remedial and repetitive. I honestly want to know where these policies are originating; they so often hurt instead of help. Is this government regulation, administrative policy, what? How many degrees removed are these ideas coming from? And why are we still implementing them? An episode on decision making in medicine would be enlightening.
Pay for performance (sometimes) works because it provides feedback about which behaviors/practices are effective. If we are shown that washing our hands ten times an hour saved three lives, then we will wash our hands more. No monetary incentive is necessary if proper feedback is given.
I think we need to get away from defining mortality as a failure. People eventually die and that fact should not be a factor. HOW they die should be what's important. We need to find a way to measure quality of life and then apply that to the outcomes for Pay for Performance plans.
As to established doctors not changing to fit these plans that's just a matter of time. Any Pay for Performance system needs to target new doctors and bring them into the mindset of quality of life mattering, and as older doctors retire then it might work.
In summary there's still potential in Pay for Performance, but so far it's just been done badly. That doesn't men it's necessarily a bad concept.
physicians do what they do because they want to help ppl. thats what i though as well from the beginning of the vid (i was a paramedic for the red cross in my time at highschool as well).
and if this is true they will do their best or at least what they believe is right even before they can get boni for whatever. so if they were at 100% from the start paying them more wont change much because u cant be much bettern than 100%.
A pay for performance system has always seemed like a good idea to me, not just in healthcare, but in many different fields as well. I know that personally I would be more inclined to pay extra close attention to detail if I knew my paycheck was riding on my accuracy. However, after watching this video it seems to me that this whole idea is a gigantic flop when applied to real life. As outlined in the video, most facilities that decided to try to use a pay for performance system had very little to no change in patient outcomes. The one study that did show a positive outcome was only done for one year which is not near enough time to notice a significant change. The study that was conducted for a longer period of time showed changes in performance at first, but all changes were gone in a short period of five years. Even the facility in Britain that offered physicians the incentive to earn up to an extra 25% of their income by improving performance had no significant change. Is it possible that we are paying our physicians too much already and that is why the incentive of money is doing nothing?
You guys really need to make more "misconception" oriented videos, ones that target the important gaps in public knowledge. Not just things like vaccination, but those that affect our day-to-day lives. I understand you've got to deal with the corporate bs first (organic food and milk) but you've also got to do the other stuff.
I really would like to see a few in particular.
How does one have good posture?- You could make an insane amount of content about this (probably even a whole channel). Not really a "to the research!" Kind of thing though.
What's the best way to deal with nosebleeds? Or hiccups, the king of home remedies? Is reading in the dark bad for you? I could list many others.
I hope you read this.
Healthcare is not like making widgets. It should not be treated like making widgets. It should not be treated as a 'business'. It should be treated as a humanitarian effort to reduce human suffering and improve the lives of all humans. 'Profit' should never, ever be involved. Quality of life is far more important than profit. People before profits.
Well, you're a commie hippie fascist socialist. I know that that makes zero sense, but I'll still call you these conflicting things because MURICA!
I don't know about you, but I totally want to spend 10 years in school and accumulate $400,000 of debt so that I can make minimum wage and be your personal slave.
You have such a great idea! I mean look at the most brilliant minds on the planet just lining up right now to take advantage of your idealized version of Utopia.
I am going to quite my job right now to become a doctor so that I can humbly serve you and provide you with everything you need. Would you like some fine wine while you wait for your free healthcare? Some caviar perhaps? Complements of the house of course... Because you're worth it.
Yeah, you're not going to get people to donate their time so your big-toe infection can go away.
Joseph Harrietha Canada makes it work. The US doesn't.
Jeremy Williams Every other first world nation has figure out a better plan then the US. All of them. We have the models we need to follow. We just won't do it.
What about using Gamification and other psychological tricks to help make pay-for-performance more viable?
While I do agree that this could help part of the problem seem to be that we have poor metrics on how to define good qualitative care.
I ask as an aspiring game designer, and I've seen a few studies about using game-design techniques to restructure workplaces for greater efficiency in general. I'm semi-wondering if you've heard of such a thing and what your opinion might be.
Ari Schwartz
I study game design my self. I think Gamification could be a very good thing. But you still need to know what your aiming for. And what I gather is that there is very little consensus on what one tries to achieve.
Of course one could always use it on minor thing that are easy to quantify. If one notice the workplace is using a lot of paper needlessly then maybe a one could some sort of reward system for lowering it. And such practices could be use at any workplace.
This could even be a temporary measure as it more about changing the behaviour for the better. Once the behaviour has been replace the new behaviour tend to stick around.
Most MD are pragmatic, they won't care about some silly acheviements. The get better efficiency they should reduce paperwork.
he191254 Oh you would be surprised how well these sort of mechanics can work directing peoples behaviour. We like to think we do all thing out of rationality. Especially if we are smart. But in reality even smart people are effected by this sort of things.
And that is sort of why they may do thing less efficient then they should. The continue to work the way they have always done. What gamification could be use for is break such behaviour. We do a lot of thing we never really contemplate about.
I would guess that pay for perfomance does not work because most doctors are motivated by helping their patients, not by the extra 200 dollars
Agree, I believe that most doctors will do what they can to help you no matter the incentive. It's actually a little reassuring that this system is not working. It reminds me a bit of my job. We get a bonus if someone turns in a good survey on certain jobs but I do the best I can on all jobs including the ones that wont get a survey. I would still do my best even if the surveys did not exist.
What about the issue of cherry picking patients that a doctor believes are the most likely to increase her metrics? Doesn't have to be conscious cherry picking to be bad? And conscious cherry picking to game the system would be worse. I think we should blend the performance and number of services model of payment.
There's a butterfly at the end of the url :) 8l8
I think the best thing to do would actually be to make health care cheaper so that people would go get treated earlier and not come with such severe problems
The issue with "pay for performance" is that it works on the assumption there's an extra mile effort being neglected.
If your average doctor is doing everything they can to help their patients, such an incentive would never prove effective.
If such a system did show results, it would do more in exposing a gains driven medical society than it would help patients.
This of course applies to anything that would test the "pay for performance" system, since it works on the assumption that low turn out is the fault of the employees' quality of work rather than the employer's responsibility of scheduling adequate labor for any given job or shift.
Of course, it's a valid logic to say the job would get done faster and cheaper if everybody working had been holding back and they just needed a fire lit under them, but it's not likely that everybody secretly is.
Summarizing, social medicine is more effective than paying for performance.
en.wikipedia.org/wiki/Social_medicine
Who cares if the outcomes didn't change? Did the price per patient go down? That is the thing that is actually important. If both systems have same outcome, which one is cheaper? If it doesn't effect the outcome at all, you should then minimize costs until the outcomes go down slightly. Then you work to improve outcomes at that cost point. Then you reduce costs again. On and on.
Are there doctors that really have the intrinsic motivation to help people or are they in it to make a buck...I say the later given the propensity for limiting appointments, no matter complexity, to under 15 minutes; making patient care a conveyer belt of get em in, move em out, and money money money. Being a patient for the last year and a half plus I've become quite peeved on quality of care.
Not good. This will just encourage physicians to give the treatment patients "want", rather than what they "need", to make sure their salary is not compromised. Just imagine all the pain management physicians who will have to give into their patients opiate addiction, and give refills just so they won't get a bad grade from their patients.
+AlexandGladys Walker
But doctors do perform pointless tests on patients. Its obvious that they keep doing way too many blood tests just so they can maximize profits. Most patients end up being anemic during their stay, and that means an extra long hospital stay. And if you are a patient, and you end up getting MRSA because the hospital did not clean up properly, they treat you for their mistake, and they charge you for it. Its based on fraud. The patient has the right to make informed decision regarding their care, and like it or lump it, the physician should respect the patient's wishes.
It really says a lot when a doctor does not even look their patients in the eye, or even spend more than two minutes with them. The emphasis is treating the disease, and that's wrong. The emphasis should be about treating the patient as a human being, yes even a smile can go a long way.
Don't bullshit me with your useless rhetoric because I see through all the lies of our fraudulent healthcare system. Here's a point. How about having cost transparency so the patient knows what they will be paying for.
+Max Maxium how do you know that the tests are pointless? Blood tests don't even effect physician pay, so there's no incentive to run pointless blood tests. Also if a physician gives you MRSA because of "not cleaning up properly" that's called malpractice and it's the physicians job to pay for the damages as a result. Where did you go to medschool again?
alex walker
I did not go to med school, but I was hoodwinked by a doctor, and so was my wife.
One day I decided to just walk out of the hospital and leave, but they said I was leaving against medical advice. Why? I couldn't afford to pay for it even with health insurance, but the evil doctor said I was to undergo 78 hrs mental health evaluation--even though I did not have any mental health problems. It was all a ploy to make profits, and they didn't care that I missed a week of work. That's why I don't trust doctors and hospitals anymore.
alex walker
You see, its all about the doctors. According to them, they are the only ones who work hard and deserve respect. Where was my respect when I told them that I would miss work?
Listen, this will only get me stressed so don't even bother replying.
+Max Maxium Then leave? They can't force you to stay, if you can't afford it then leave? They can advise all they want but you left right? They didn't tie you down and steal your wallet and bank card did they? Just like a car dealer can't force you to stay and buy the car, a physician can't force you to stay and buy the treatment. So what's the problem?
Its disappointing that an incentive has to be offered in order for the physicians to do their job. Which they should be doing in the first place. The studies have shown pay for performance works for a short period of time if at all. They claim it would increase the quality of the patients healthcare, but what exactly is "quality" healthcare. Some people say it would decrease healthcare spending. It's possible that giving bonuses out to physicians could increase healthcare spending if the they are prescribing unnecessary tests and medications creating the illusion that they are providing "quality" healthcare. Is it possible that doctors could be blinded by their greed? Like he mentioned there is no evidence that pay for performance can change physician behavior let alone patient outcome.
I think this video is saying the opposite. A doctor being paid bonus for performance gets you negligible or no effect, because they are already doing their best. The doctors aren't making these policies, business people and politicians are - both live in a world where you have to be paid before you do a good job. It doesn't match the health industry
What about paying Doctors when you are healthy instead of when you are sick?
Well it might sound a little harsh but if this is what he have to do to get healthcare then so be it. Its really sad that money has to be included as a prize for doing something that you should already do to the best of your ability which is providing quality healthcare. True that doctors will be doing things for the wrong reasons by maybe this is what it will take to minimize the extremely high incidences of malpractice, and high rates of malpractice suits. Pay for performance proves that majority of people go to college and get into careers just for the money, not for the desire to help others.
Couldn't states or schools use doctors' required residencies to screen social security beneficiaries and/or act as their primary providers at clinics? Incentivizing and educating doctors before the real drama begins
Incentives is great motivation, but not in healthcare. Doctors may cross boundaries to achieve these incentives. The money that healthcare providers make is a definite motivation for students wanting to purse a career in this field of work. When we start to base doctor's pay on how many treatments they administer is a grey area. For example, it could become more costly to the patient. If we pay for performance who is to say that the doctor does not prescribe their patients with unnecessary treatments to reach that extra pay. Quality of care would be diminished because the doctor would lose their morals and go for the extra money. Care would go in a downward spiral and the healthcare that people have tried so hard to improve would be setback and start to regress.
It's pretty difficult for doctors to change behavior when in Western countries doctors are heavily regulated and railroaded to provide services a certain way to keep their licenses.
Capitalist healthcare hospital perspective 🏥 step one find people facing pain and mortality step 2 negotiate with them via your insurance buddies
Pay for Performance is one of the few aspects where I can see both point of views.I completely disagree because doctors work hard to get their title. They can only do so much. What happens if an individual is greedy and refuses to get certain labs done or exercise correctly like the doctor insisted? Then what? It's not fair for the doctor to get "punished" if his or her patients aren't cooperating. On the other hand, I believe Kant came up with a good definition for this situation. A hypothetical imperative demands performance of an action for the sake of some other end or purpose. The purpose here would be to get doctors to do anything and everything they for a patient. They will then be obligated to perform to the best of their ability to achieve a legitimate goal. But don't doctors do that already? Don't they already do everything they can to help their patients no matter what the incentive is? Doctors have no control over their patients so this wouldn't be a fair situation.
exactly! I see this all the time now. and with the internet, people feel more emboldened to tell the physician what they want instead of listening to the physician suggests. most physicians want to help people, but they are not gods. they can't "work miracles".
Who's paying for the performance? Who is figuring what quality is?
The hospitals and QA boards respectively.
***** Oh I see. I thought it might be central planning. I just hope people don't use this as evidence that profit motive doesn't work.
George Cataloni There is plenty of other evidence that profit motive doesn't work.
***** You mean for healthcare or in general? Can you cite anything?
George Cataloni For a casual example, China's healthcare system; wherein availability of specialists are allotted by tickets which are often then scalped to the highest bidder.
If your concern is only for the individual then sure you could make a fairly compelling case that an individual's ability to pay any price might well reward them with the highest quality healthcare around but I would question your moral grounding if you think that systems like healthcare should be organized to benefit individuals over society as a whole.
Pay for performance sounds great in theory but in reality it does not work. Awhile back Medicare/Medicaid gave patients a $25 gift card if they would come to their scheduled yearly physicals or well child exams. Only about 25% of those scheduled actually came to those appointments. Money is not an attractive incentive as it once was.
Pay for performance is not a good thing to implement. I feel like if this was implemented, it could get a little out of hand. Sure, there could be the good doctors out there that will actually operate under good premises, but if a doctor has a patient that does not have a good outlook, who is to say they aren’t going to let the patient get worse because they won’t make money off of them? I do believe that good work should be rewarded, but there are other ways to reward someone. We are transforming healthcare into a business rather than a means to getting someone the proper care that they need.
+Lexie J I totally agree with what you are saying. Even though pay for performance may initiate the wrong motives then maybe this is what needs to be done to reduce so many avoidable medical errors causing many patients deaths. Healthcare is being transformed into a business and morally speaking this is not right at all. Pay for performance will not improve patient physician relationships either because of the distrust consumers have with doctors. most patients already feel as though they are just a walking experiment.
I agree that there may be a potential to create a business of healthcare rather than having an altruistic field focused on curing disease and alleviating human suffering, but assuming that pay for performance would affect this issue is flawed on two major tenets. First, the data presented by Dr. Aaron Carroll in this video does not show or even allude to the fact that pay for performance has any negative effects on the care received by patients. To the contrary, there may even be slight benefits associated with pay for performance! The only real way to settle this argument would be to conduct more studies and gather more data, but using an assumed outcome rather than gathered data does nothing to help solve the issue. Secondly, would you not pay more money to go see a physician who you knew was the best in the field? There is a reason some doctors make more money than others. It is immoral to say that doctors should not be rewarded for good work. Not rewarding proper healthcare could potentially result in worse healthcare delivered and worse patient outcomes. This system should not be instituted by hospitals, but governed by the free market principles of capitalism. This is the only way for such a policy to work in the economic framework the United States has set up. This would eliminate the potential of physician malpractice for financial incentives, because patients can sue for malpractice, and even one public lawsuit would affect other patient’s opinion of that doctor, thus resulting in further denigration in pay. Additionally, you assume that physicians make decisions for financial gain rather than patient outcomes. I, from my experience, have a higher opinion of most physicians.
How about we stop worrying about incentivizing doctors to do better with carrots, and start punishing them with the stick when they refuse to do better?
Last I checked, if you don't do your job in most jobs, you don't keep your job. So screw tenure, if the assholes can't produce, then they lose their license. Simple as that.
>start punishing them with the stick when they refuse to do better?
Leads to defensive medicine. Worse outcomes and higher costs. This has been studied and talked about on this very channel.
>screw tenure
What doctors do you know with tenure?
Overall I found this video disappointing. This video is implying that doctors are simply not doing their best for their patients. Don’t get me wrong there are some doctors in the world that do their best for their patients and pay does not concern them. But the video is implying doctors don’t work as hard as they could for their patients simply because they don’t believe they are being paid enough. Instead of being paid for performance I believe they should be paid by the amount of time they are spending time with a patient. Spending more time with the patient could help make improvements
I do not think that pay for performance is a good idea. Knowing that physician would work harder because they may receive a bonus or better pay is kind of frightening. Why is money motivating a physician to do better quality of care? A patients care should be treated the same rather a physician is getting paid more or not. Yes, top physicians should be paid more for their work, but it shouldn't be looked at as ‘if I do good I’ll get paid more’ or ‘if I don’t get a bonus I won’t try my best’. I believe pay for performance could get messy. Making physicians even more money hungry. The health and care of the patient is number one, no matter how much anyone is getting paid. The physician should get his patients chronic illnesses under control no matter what, and if he does an amazing job over all he should get a raise, like most jobs.
I don't exactly agree with pay for performance. Yes, it leads doctors to strive towards providing better healthcare. But what exactly is "better healthcare" to the patient? It isn't just putting a smile on your face and putting on an act, it is providing good solid healthcare without malpractice. I think that pay for performance is going to cause doctors to do things for the wrong reason. Instead of doing their job because they want to help, now it will be doing their job because they will get a bonus, and slacking if not. It is really hard to measure quality of care, I think that quality should be above quantity, but there may be different views on what quality of care is. Every doctor obviously shouldn't be paid the same, but they should prove themselves overtime without bribery for a large salary.
Guess someone on staff got a little hungry? All the gum balls from the red plastic pill on the credenza are gone!
First?
Garbled.