BMJ paper. "The impact of removing financial incentives..."

[Neuro Surg]

http://www.bmj.com/cgi/content/abstract/340/may11_1/c1898

Is anyone actually surprised by the results of this study? I mean, what did they think would happened if incentives were removed? Physicians are not immune the laws of economics- wow, what a revelation.

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[MOHS_01]

 

[thedrjojo]

Agreed... I don't know if the incentives are on a per person basis or on a percentage of practice basis... Most insurance is paid solely on a volume basis, but it seems from the abstract that Kaiser pays PCP's based on x percentage of your patients receiving x screening or obtaining x goal, which is the incentivation that SHOULD be included in medicine (ie, outcomes based).

I said long ago, compensation should be a combination of salary (baseline salary based on number of patients you have, as hmo's pay you x money per person to provide care for) plus compensation per visit/procedure (so salary is almost like a subscription to have a doctor, the compensation per visit/procedure equates for differences in usage) and then compensation based on outcomes (stratified for number of patients with measurable outcome, incentive based on % that meet the outcome, like % HbA1C < 7, HTN < 130/85 for our PCPs, or Complication rates or survival numbers for surgeons, etc). This combo deals with people not having PCP's, fear of over utilization, and incentives for proper practice of medicine

 

[bronx43]

The incentive model has been brought up numerous times, but people never took it seriously (except apparently Kaiser).
I was under the impression that most doctors oppose this reimbursement scheme.

 

[thedrjojo]

The incentive model has been brought up numerous times, but people never took it seriously (except apparently Kaiser).
I was under the impression that most doctors oppose this reimbursement scheme.

yeah, cause it holds them accountable for outcomes instead of just volume. plus they blame the patients for not meeting the goals instead of themselves, and don't want to practice medicine "cookbook" style, even though algorthyms have been shown to out perform clinical judgement (see Sepsis ED Algorthym)

 

[MOHS_01]

The incentive model has been brought up numerous times, but people never took it seriously (except apparently Kaiser).
I was under the impression that most doctors oppose this reimbursement scheme.

Meh... you will always find a vocal group of people who fear or resent change, but the reason that docs were apprehensive of this was due to the specifics of the proposed arrangements and the incentives inherent to the system.

yeah, cause it holds them accountable for outcomes instead of just volume. plus they blame the patients for not meeting the goals instead of themselves, and don't want to practice medicine "cookbook" style, even though algorthyms have been shown to out perform clinical judgement (see Sepsis ED Algorthym)

Wrong, but not surprisingly so... This has been the knee jerk response, but the problem is multifaceted -- patients are not homogeneous objects, like a block of ice or steel, that responds rather uniformly and predictably. Principles that hold true for aggregates do not necessarily hold true for the individual as this proposed method would assume. One can follow the guidelines and do the exact same thing over and over for every patient and experience a variety of outcomes. Perhaps you will better understand this as you go through the process and gain experience........

 

[dilated]

yeah, cause it holds them accountable for outcomes instead of just volume. plus they blame the patients for not meeting the goals instead of themselves, and don't want to practice medicine "cookbook" style, even though algorthyms have been shown to out perform clinical judgement (see Sepsis ED Algorthym)

No, it holds them accountable for process measurements which may or may not have any relation to actual patient outcomes. If it held them accountable for outcomes it would be far more tolerable. The decline in "performance measures" probably just means that people put less effort into gaming the numbers.