Is the Doctor Pay Model a Solution?

The New York Times, Feb. 1, 2013

PNHP note: the four letters below were among those published in the Feb. 1 edition of the Times in response to an article earlier in the week by Bill Keller on pay-for-performance schemes. For more on the hazards of such schemes, see “Will pay for performance backfire? Insights from behavioral economics,” by Steffie Woolhandler, M.D., M.P.H., Dan Ariely, Ph.D., David U. Himmelstein, M.D., at the Health Affairs blog, Oct. 11, 2012.

To the Editor:

Thanks to Bill Keller for responding to fads with facts (“Carrots for Doctors,” column, Jan. 28).

Of course, as he suggests, physicians need to be held to professional norms. But until we join the rest of the industrialized world, where health care is publicly financed and a public good, we are unlikely to see the substantive cost controls that misdirected schemes like “pay for performance” supposedly address.

At best, these schemes are tinkering with the system; at worst, they end up costing more and delaying the real reforms that are necessary.

Middlebury, Vt., Jan. 29, 2013

To the Editor:

Great: pay for performance.

The problem with the current approach is that it forces the performer to document his performance by clicking boxes and repeating hollow attestations. This mostly just takes away from the real work of trying to take care of patients, which has become subverted in the pursuit of “documenting” the desired performance.

The underlying assumption is that without this documentation, doctors will perpetrate fraud.

To this end, I am forced to attend fraud awareness sessions, which teach me what boxes to check and what attestations I must make to be in compliance. We get it: it all costs too much.

But a medical bureaucrat’s idea of what should happen in a medical encounter for it to be billed at its current exorbitant level has created a nightmarish scenario that will result in much worse, more costly care.

Chicago, Jan. 29, 2013

The writer, a geriatrician and ethicist, is an associate professor of medicine in the Pritzker School of Medicine, University of Chicago.

To the Editor:

Bill Keller’s column explores ways of dealing with our overpriced, underperforming health care system but ignores the elephant in the room: the insurance industry.

Thirty percent off the top of our health care dollar goes to the insurance industry’s profit and overhead. There are also the hidden costs to physicians and hospitals that employ an army of workers whose only job is to deal with the paperwork for each claim. At the back end is the cost of malpractice insurance. Again, with an unknown percentage of profit.

This enormous expenditure adds nothing to the quality of health care, though it does add hours of work and anxiety to the sick, physicians and hospitals with the hope of reimbursement.

This is the low-hanging fruit of cost control without compromise to quality care. We should pick it.

New Rochelle, N.Y., Jan. 28, 2013

To the Editor:

Neither carrots nor sticks promote professional performance or pride, whether they come in the form of monetary incentives or threats of public humiliation.

We’ve known for decades that extrinsic rewards and punishments are successful only for short-term simplistic goals, yet the idea persists in crucial areas of national need like education and medicine, undermining substantive progress.

Hoboken, N.J., Jan. 28, 2013

The writer is director of the Center for Innovation in Engineering and Science Education at Stevens Institute of Technology.