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?