Standard of Care vs. Pay for Performance

Standard of care or community standards are very important because they determine whether a health insurer will pay for a service or not. In an ideal world, standards of care would correlate closely with evidence based medicine that leads to favorable clinical outcomes. However, this is not always the case. Sometimes standards of care do not produce the best results with the least side effects and sometimes practices and procedures that produce favorable outcomes are not considered standard of care. This speaks to the fact the medicine is a mixture of art and science. Apparently, health insurers pay for science not art, regardless of the outcomes.

Pay for performance, or P4P as it is sometimes known, in the non-health care world refers to results, regardless of the process to achieve those results. In health care, there is a strong focus on the process and less on the actual results. The theory is that tried and true process brings about good results that would not otherwise be achieved by other methods outside the standard of care. This is not always the case.

Case in point, recent studies suggest that the popular antidepressants are no more effective than a placebo and in fact may be worse, given the side effects that come along with the drugs. The popularity of antidepressants is based on a seminal study in 1998 that demonstrated that they were safe and effective. However, when two researchers, Irving Kirsch and Guy Sapirstein of the University of Connecticut compared the improvement in patients taking the drugs to those taking a placebo in double-blind studies, they discovered, based on drug companies own study data, that patients on a placebo improved 75% as much as those on the drugs. So if a patient were given the drug, whether they improved or not, it would be paid for. However, if a patient were given a placebo and improved, it would not be paid for. In other words, clinicians are paid for what they do, not what they accomplish.

I am not suggesting that clinicians only get paid if a patient improves due to the clinical intervention, but I am suggesting that this is a complicated dilemma and we need to better understand the art of medicine. Recently, a primary care physician told me that a patient that she had been treating for many years was not following through on her advice and continued to complain about the same issue at every visit. Finally, she took the patients hands in hers and asked the patient what she could do to help her. The patient with a tear in her eye said "tell me you love me and that I am a worthwhile person". Having done so, the patient’s quality of life improved immeasurably. How does that factor into the standard of care verses the pay for performance debate?

Disease Management – Does it Work? Yes and No!

A recent article in Business Week reported that "Washington wants to pump big money into disease management, even though there’s scant evidence that it works". So what is disease management anyway? Essentially, it is a process where people with certain chronic diseases are flagged and contacted by disease management professional to assist them in doing the things necessary to control their condition. Typically, this disease management professional works for a company that provides this service over the phone. The disease management professional is armed with good ideas but is not someone who is known (or always trusted) by the patient.

Disease management sounds great. Who could argue with managing your disease better? This great idea created yet another layer of healthcare bureaucracy between patients and their doctors adding more costs to the healthcare system under the guise of saving money. GE, who was a leader in this movement, poured a lot of money into their program over a ten year period only to find out that it didn’t really work. According to Bob Galvin, GE’s chief medical officer, GE didn’t see any compelling evidence that it saved money or substantially improved workers health.

Why didn’t it work? Conceptually, it makes so much sense that disease management interventions that have strong evidence of improving patients health and wellbeing has to be a winner. In a typical analysis, if the concept is sound, one looks to the execution as the cause which leads me to believe that the message about health and wellness is coming from the wrong messenger, i.e., anonymous hired agents by health insurance companies. Instead, if the message came from a person or organization that the patient knows and trusts, it would seem logical that the results would be far better. So who do patients know and trust? Why their doctors’ of course.

What if doctors were given incentives (payments that would otherwise go to disease management companies) to establish a disease management program and the word came from the doctor’s office not from an unknown voice over the phone. I believe that patients would take this advice more seriously and it would eliminate conflicts between what the doctors recommend and what a disease manager from an unrelated company recommends. So if this makes sense, why isn’t done? I believe that answer is that there is a lack of collaboration between providers and payers (the doctors and the health insurance companies). For us to make any progress in this area of health care, there needs to be a why to bring the payer and provider forces together.

Market Driven Health Care Reform

Health care reform that addresses cost, quality, and access will not happen from the top down given the results of the Massachusetts election, the Supreme Court ruling that allows unlimited spending on political campaigns, and the broad based distrust in government as pointed out by David Brooks in the NY Times. I foresee that we will continue on the path of more out-of-pocket spending by those who can afford to pay, federally funded community health centers, charitable organizations, and emergency room backup for those who cannot afford to pay and major growth in medical travel. We are backing into a consumer driven system that will rely on competition among providers, both domestic and foreign, to control costs.

We will continue to tolerate the physical and financial suffering of a minority of the American population to support the success of the health care industry as long as the minority remains at the 15 to 20 percent level.

Bottom line, it is highly unlikely that any direction and leadership will come from Washington. We probably have a better shot for patch work reform on a state by state basis.