Pay for performance--a clash of cultures.

The experiments with pay for performance portend a seismic shift in the practice of medicine in the United States. Much has already been written about aligning interests of the various health care providers, chiefly being the hospitals, federal government through the Centers for Medicare and Medicaid Services (CMS), health care insurance carriers, and physicians.

What has not been clearly addressed is the monumental clash of cultures that will occur with implementation of pay for performance, and the impediments that it presents. As with any medical diagnosis, it is helpful to look to history to identify some of the factors that have brought us to this point.

* 400 BC: Hippocrates codifies the practice of medicine and establishes a philosophical approach that endures to this day. His thoughts, among others, established the physician as the ultimate arbiter and advocate of what is best for patients, at all times and against all competing interests.

* 1983: Institution of diagnosis-related groups (DRGs)--these rapidly became "the law of the land" and the methodology used by Medicare and many insurers to codify and reimburse hospital care.

* 1999: Institute of Medicine report, To Err is Human: Building a Safer Health System. Although controversial at the time of its publication, and still widely debated as to the accuracy of its statistics, the report clearly showed that health care in the United States was not as safe as it presumably should be.

* 2001: The Institute of Medicine issues its followup report, Crossing the Quality Chasm: A New Health System for the 21st Century, recommended a fundamental redesign of the American health care system. The report called for alignment of payment and accountability by incentivization, the promotion of evidence-based medicine, and the strengthening of clinical information systems.

* 2004: President George W. Bush issues an executive order on April 27 calling for widespread deployment of health information technology within 10 years to help realize significant improvements in the safety and efficiency of health care delivery.

* 2011: Baby Boomers reach Medicare eligibility. Although estimates vary both widely and wildly, it is anticipated that Medicare expenditures will exceed $1 trillion at that time.

What may not be readily appreciated from this linear perspective is that this timeline incorporates three roughly parallel, but not necessarily concordant, perspectives. These may be conveniently summarized as:

* The physician: "I am called by my profession to do what is right, in my eyes, at all times, regardless of cost, and I will defend my patient against all threats to the quality of care which I am charged to deliver. Besides, if I don't, I am going to get sued."

* The hospital: "Our medical error rate is unacceptable; we must invest time, effort and funds to become compliant with current standards, by which we are being rated. Besides, there is competitive market value in being rated highly; and it is more cost effective to prevent errors than to treat them."

* The federal government: "We have excessive costs that are unsupportable at current projections, and a lot of evidence to suggest that we are paying excessively for mediocre care. Something must be done!"

Because hospitals have generally accepted the argument that real-world business models do have some bearing on the modern delivery of health care, they have made common cause with insurance carriers and CMS in moving toward implementation of safety models and efficiency standards.

To a varying degree, most, if not all, hospitals and very large group practices have instituted electronic records, computerized medication administration systems and other modernized practice methods. Almost all pay at least lip service to the concept of a portable, electronic health record.

By their hierarchical nature, and adherence to a corporate model, hospitals have been able to institutionalize some of their goals by fiat. Nurses can be required to use computers, bar code scanning of patient identifiers can be made mandatory, electronic medication administration systems can be made compulsory. And, since hospitals operate on a business model, incentivization is an understandable concept, in a world of competition--competition for patients, for advertising, for admitting physicians.

Little or none of this applies to the physician. Trained from the outset to think independently and to value medical ethics to the virtual disdain of monetary drivers and non-medical factors, physicians as a whole have not bought into the argument that any of this has any relevance to the delivery of quality medical care.

As hospitals invested increasingly large resources in medical records departments, utilization review, quality assurance and computerized information systems, physicians are regularly heard to complain that not one cent of this massive investment has improved the quality of care.

Rather, such investments are perceived to have drained funds from the acquisition of medical equipment and nursing staff, which are necessary for the real practice of medicine and surgery.

[ILLUSTRATION OMITTED]

These perceptions are coupled, in the minds of physicians, with the equally hostile market trends of increased liability (medical malpractice suits), increased costs of running a practice and declining reimbursements, with the very real threat of further declines to follow.

Contrary to the intent of the IOM report, the push toward an electronic medical record, has only added fuel to the burning argument that the bean counters and lawyers are running, and ruining, the practice of medicine. More than 50 percent of physicians are reported to have informed the AMA that they will delay their purchase of new information technologies as Medicare reimbursements decline.

So as hospitals and insurers move toward standardization of care, application of evidence-based medicine and best-practice methodologies, they are met, on the physician side by incredulity, if not outright hostility.

Ultimately, it is the physician who has to implement these changes (so that the hospital can capture the incentives), but who bears the brunt of the liability and the expense, without perception of definite benefit--either to the patient or the physician.

Free agent physicians

Unlike the rest of the hospital family, the physician is the free agent. And, by virtue of their ethical tradition, physicians will not be compelled to implement these changes, because the very incentives being recommended are ethically abhorrent.

If physicians demonize HMOs for their monetary restrictions on care, recoil from the concept of selling organs, and refuse to participate in gain sharing arrangements in return for a restriction on their freedom to choose which implant is best for their patients, how can one expect that a +/- 2 percent change in reimbursement is going to be a compelling tactic?

There is also a lesson to be learned from an earlier experiment into incentivization--the so-called "second pool." In this now-discredited scheme, primary care physicians were tantalized with the prospect of year-end bonuses, additional income from presumptive savings in reducing referrals for expensive consultations and unnecessary diagnostic studies.

Instead of serving to increase cost-benefit risk analysis on the part of physicians, however, the plan simply worked to erect obstacles to timely referral, impeded the delivery of quality medical care, denied benefits to many HMO patients, and left the HMO industry with a lingering taint.

As has been often stated, physician-based medicine represents the last cottage industry in the United States. And therein lies the fundamental disconnect between the corporate top-down model of incentivized modernization of health care delivery within the hospital, and the individual most responsible for implementation of the most critical element of the program.

If past performance is any indicator of future behavior, we should understand that the economic model has had little impact on physician behavior. Past and future Medicare cuts have not changed practices into more efficient providers of care, but have, instead, reduced the numbers of participating providers, and led directly to the establishment of concierge and boutique practices, re-establishing the stratification of health care delivery in this country.

What motivates physicians?

It is fascinating to observe, as I have on numerous occasions, the remarkable confluence of viewpoints of practicing physicians despite disparate backgrounds.

Although as divided on issues of gun control, abortion and political affiliation as the rest of the country, physicians attending a meeting of medical and non-medical health care executives offer a remarkable uniformity of opinion on health care, despite wide differences in specialty, training and regional practice.

All strive for quality, but see its implementation quite differently from non-physicians. None sees economic incentives as a motivator and disincentives are perceived as inherently unethical.

Across many specialties, there has been an increasing trend toward analysis of so-called Class 1 evidence. This is hard to come by, for it demands randomized, double-blind, prospective studies. Patients are selected by lot, with neither the patient nor the treating physician aware of the specific treatment, and with the outcome assessed, at a future date, by an unbiased observer, unaware of either the treatment, or the patient.

Remarkably, very little Class 1 evidence exists today about most of what we do in the practice of medicine and, especially, surgery. In neurosurgery--my field of practice--a recent analysis concluded that almost nothing we do is based on Class 1 evidence (despite a lot of agreement on so-called "best practices"), and that a lot of what had been accepted as a standard of care was, in fact, without basis in fact.

A good example of this can be found in our recent reevaluation of the use of steroids following spinal cord injury.

Fifteen years ago, neurosurgeons were being sued for failure to use steroids--the presumptive standard of care--only to find, on recent analysis, that there was no clear, statistically significant basis for the use of steroids in all cases and, in fact, some evidence to suggest that their unrestricted prescription was actually associated with increased complications and worse outcome.

More significantly, Class 1 evidence can never, and will never, be obtained for many disease conditions and surgical procedures. How, after all, can one randomize some infants to a sham operation, some to "blind radiation" (i.e., without a tissue diagnosis obtained by surgical biopsy), and some to a proposed surgical resection, in a modern, ethical, Western culture?

If the Nazi experiments at Auschwitz are considered so ethically abhorrent that any utilization of the data gathered in those experiments cannot be considered or cited, how are we to establish treatment of so many conditions except by retrospective review of outcomes?

Certainly where there is no satisfactory standard, prospective studies can be carried out to test one versus another medication, as for treatment of hypertension, or angina, or lowering cholesterol. But once there is a satisfactory therapeutic option, withholding treatment or performing sham surgical procedures cannot even be considered.

Clearly then, there is no ready solution. There are some options, however, that may represent pieces of the health care jigsaw puzzle we are trying to assemble.

The first piece of the puzzle may well be a determination of best practices, within the various medical and surgical specialties. Not as compelling as Class 1 evidence, best practices ideally represent the consensus of opinion of those generally regarded by their colleagues as being in the forefront of practice, and the prevailing opinion of those practicing in the field.

Implementation of best practice guidelines in a hospital would allow the physician to rapidly implement the contemporary standard of care for a given patient, while permitting him to opt out, on a line-by-line basis, to accommodate the particular requirements of a given patient.

Best practice standards also avoid a common physician complaint--that outsiders are imposing "cookbook medicine." Although there are several instances where standardization of practice has reduced risk and improved outcome--coronary artery bypass grafting (CABG) being a stellar example--all physicians agree that patients are not automobiles on an assembly line and the variability of diseases across an enormous spectrum of patients always presents the challenge of an uncontrollable "X factor."

The second piece of the puzzle is rapid deployment of computerization across the enterprise for hospitals and physician practices. In this case, the Stark laws, which prohibit providing inducements to those who are in a position to refer patients to a hospital represents a major impediment to the modernization of health care and must be re-written.

Without some financial incentive, most physicians will be neither in a position, nor of a mind, to invest in the requisite equipment, software and training to permit implementation of electronic records, prescription programs and electronic links to hospitals.

Given the choice between two percent more money on their Medicare patients and a computer on the desk linked directly to the hospital with real-time access to test results, patient monitoring and radiology studies, the overwhelming majority of physicians will choose the latter because it's better for patient care, more efficient, provides better quality of life, less hassle and no accounting burden.

The third piece of the puzzle is rapid adoption of a standard for information technology by CMS that will offer compatibility across all organizations and individuals, eliminating the fear of investing in an incompatible system.

Everyone understands obsolescence. Nothing lasts forever, but adoption of a standard not only permits the establishment of connectivity and compatibility, it also speeds adoption.

The fourth piece of the puzzle involves relative immunization from lawsuits for physicians utilizing best practice methodologies, regardless of outcome. Although this presents a challenge for the American system of jurisprudence, physicians perceive themselves to be under attack by lawyers who hold them accountable for adverse outcomes not under their control, and judgment by a jury system that includes everyone except their peers.

It bears emphasis that the concept is relative protection--not absolute immunity from gross negligence or a failure to document the rationale for deviation from the established best practice. But adverse outcomes occurring despite application of best practice methodologies, as attested to by an independent review organization, would be considered prime facie as appropriate care and, in the event of lawsuit, adherence to the standard would be admissible into evidence as an almost insurmountable burden for the prosecution to overcome.

A fifth piece of the puzzle is using e-mail in patient care. Almost without exception, doctors today use e-mail for correspondence across a wide range of relationships--except patient care. Their concerns are understandable.

Except in a few trial circumstances, insurance carriers or Medicare do not reimburse patient correspondence by e-mail. Therefore, physicians are understandably unwilling to spend time on something that is not reimbursed.

Secondly, response to e-mails, without having seen or evaluated the patient is widely perceived to increase liability exposure. So the promise of rapid, written correspondence, with an electronic "paper trail" goes unfulfilled. The answer here is obvious and Medicare should lead the way.

It goes without saying that such proposals cross many spheres of influence, and are not likely to occur rapidly. However, if our goal is to move with deliberate speed to a health care environment that is safer, more efficient, more interconnected and more readily accessible, these suggestions, among others, should be considered seriously, rather than blindly throwing money into the wind.

Lawrence H. Fink, MD, MS, FACS is medical director of Doctors Hospital of Sarasota, Fla. He can be reached at 941-379-3030 or [e-mail]

[ILLUSTRATION OMITTED]