Tuesday, May 22, 2012

The Outcome Fudge Factor

How hospitals will be paying cardiologists in the years ahead:
“Two or three years ago, 100 percent of cardiologist compensation was base pay,” he said. “Increasingly, that has shifted.”

Administrative time and performance incentives are factored in when considering the total take-home pay of a cardiologist. While most of a cardiologist’s income still derives from a base salary, Mr. Palazzo predicts that will change.

“As accountable care moves along, it could go to as much as 50-50 three to five years from now, where 50 percent is paid based on outcomes,” he said.
I find this concept of paying doctors "based on outcomes" interesting but also troubling.

If you do an echo really well and take a million measurements when others just do the bare minimum - what's the outcome?  If you spend four hours with a patient when others spend 15 minutes a patient, what's the outcome?  If a patient has chest pain, gets stented, goes home the next day, but an expensive drug eluting stent is used where a bare metal stent would do, what's the outcome?   If the patient dies despite doing everything correctly duing a three-week hospital stay, what's the outcome?  If you order a test because the family insists, what's the outcome?

What "outcomes" are hospitals taking about?  Outcomes for the patient, doctor, or hospitals themselves?  Are physician outcomes going to be based on "quality metrics" (like open encounters, performance measures completed and percentage of generic drugs prescribed),  quantity of patients seen per week who didn't die,  "Best Doctor" status, or corporate politics?

I wonder if a "good outcome" will really mean nothing more taking in more money than you spent on providing patient care. 

Does anyone really have a clue what "outcome" fudge factor means? 

I suspect not.

More likely what will evolve in my view, is that doctors' productivity bonuses will disappear in favor of straight salary with their income docked if simple, easy-to-measure "quality measure" endpoints are not met. 

Unfortunately, just because endpoints are easy to measure, does not mean they make a difference for our patients.



Keith said...

This will be the biggest challenge of the new paradigm of medical payment. Presently, it is based only on a theoretical concept that we can encourage better outcomes by rewarding those with the best outcomes. But defining what outcome is to be expected in medicine is very difficult when you deal with unique biological systems that do not always conform to the standards of care.

I would suspect we are about to suffer the same frustrations that teachers are now having. No Child Left Behind placed a lofty goal that all kids would be brought up to grade skill level in so many years, and that schools that did so would be rewarded with federal dollars. As we now know, the bar was likely set too high and the expectation that teachers were held responsible for reaching these standards when there are so many other varibles affecting whether a childs ability to acheive these goals (parental involvement, stabilty of the home enviorment,developmental and emotional disabilities, IQ, etc etc.) was ludricous.

Then again, if dollars that are now used most intensively in hospitals trying to cure years of chronic problems that are neglected are moved to more proactively deal with these issues, maybe we can actually keep people more healthy rather than putting patches on the problem after the fact.

The great experiment is about to begin!

Andrew Price said...

I think this is ridiculous. When healthcare and the procedures could be most improved by streamlining and simplification the powers that be want to impliment strategies that will only serve to increase administration and paperwork. I guess the bureaucrats have managed to figure out yet another way to justify more work and more money for themselves.

Anonymous said...

It gets even better! The COURAGE trial shows that 30% of patients treated with medicines vs stenting will bounce-back thereby signifying poor patient care. However, performing stenting on all patients constitutes over-usage which is now being policed by our beloved ACC. Over-usage is poor quality which begets lower reimbursement.

To summarize: if you treat with medicine, it is low quality with a bounce back. If you stent, low quality again as "unnecessary" care. In both cases, you fail to meet benchmarks and your pay is cut. ENJOY.

Anonymous said...

Dr. Wes,

Off Topic but so important to you and your colleagues, your patients, and their families. I URGE you to read this incredible and honest article from New York Magazine by Michael Wolfe about the consequences of extending life.