White Coat Notes

Studies question medical rewards

Programs that reward doctors and hospitals for hitting certain quality targets are being rolled out in Massachusetts and across the country. A major focus of the health care law signed by Governor Deval Patrick last week is that doctors should be paid for keeping patients healthy rather than for the volume of tests or treatments they order. Yet, several recent publications question whether pay-for-performance systems actually lead to better care for patients.

A review of seven studies of primary care programs that paid doctors extra for meeting certain targets, published by the Cochrane Collaboration in September, was inconclusive about the effect on quality of care. “Implementation should proceed with caution,” the authors wrote.


A study published in March in the New England Journal of Medicine found that a large Medicare pilot program that paid providers more if they met certain process targets — and docked those who did poorly — did not reduce short-term patient mortality rates. A version of the program is being rolled out nationally. The authors of the paper called the results “sobering.”

In an editorial published Tuesday in BMJ, formerly known as the British Medical Journal, two public health professors and a best-selling author in the field of behavior economics explain why they think paying doctors more based on quality metrics is inherently problematic.

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Hospitals and doctors can easily change their reporting practices to improve their quality scores, they wrote. And financial incentives can undermine doctors’ intrinsic desire to help their patients, wrote Drs. David Himmelstein and Steffie Woolhandler, both professors at City University of New York and visiting professors at Harvard; and Duke University professor Dan Ariely.

The idea that people will be motivated to do better if they are paid more as a result may seem like common sense, but medicine is complex, Himmelstein said. Often the measures used to determine success do not match the conditions of care or patient outcomes the program is meant to address, he said. Himmelstein said other fields have struggled with pay-for-performance programs. Under national education policy, schools that score poorly on standardized tests receive less funding. “They’re the ones who need it most,” he said. “Is the right reaction to poor quality that those institutions need fewer resources, not more?”

West Nile worries

Mosquitoes are on the minds of many in Massachusetts, after state officials announced last week that a Middlesex County man is his 60s is recovering from West Nile virus.


The Massachusetts Medical Society and the state Department of Public Health, in partnership with HCAM-TV in Hopkinton, this week released a video report on diseases carried by mosquitoes and ticks, their symptoms, and how to prevent them. See the full video online in the station’s Physician Focus section.

Chelsea Conaboy can be reached at Follow her on Twitter @cconaboy.
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