Newtown, CT – Aug 24, 2012
It's usually dangerous when we confuse the talkers for the doers – A recent paper published in the British Medical Journal had an innocuous enough title: "When Financial Incentives Do More Good Than Harm: A Checklist", and yet it set off a firestorm of reports across the US that concluded (because of an accompanying editorial by physicians advocating a single-payer system) that incentive programs such as P4P are ineffective, at best, and mostly dangerous. Really? Come on man! About ten years ago, when we launched Bridges To Excellence, there were a handful of physicians across the country that were publicly recognized for delivering good care to patients with certain chronic conditions. Today there are close to 20,000 and the results have been well studied and published for years – quality of care has improved and costs for those conditions have gone down (psst…even Health Affairs has discovered that better management of patients with diabetes leads to savings, so it must be true!!). And let's get real. If incentives didn't matter, then medical cost inflation wouldn't have grown at a far faster clip than the growth in GDP. Fee-for-service fuels the production of services because that's the incentive it creates, and it's worked very well…too well, which is why we're in the mess we're in. And as Jeff Goldsmith reports, it has vaulted the health care industry into an alternate economic universe, one in which the laws that govern the rest of the economy don't apply. So what's dangerous isn't P4P, it's the lack of it.
What this means to you – The talkers and hand wringers are an interesting bunch and are useful in reminding us that we should be rigorous in developing new payment experiments. But you should never confuse them with the doers. It's easy to sit back in front of a screen and, with the benefit of perfect hindsight, determine what the best course of action should've been. The BMJ authors propose a nine-point checklist to use before embarking on any new incentives improvement intervention, and if you use that checklist, I'll pretty much guarantee that you'll never implement anything again. So here's a far simpler one: (1) Are you satisfied with the current state of patient care? (2) Will it improve without an intervention?
If you answer yes to either of these questions, then you're in Jeff's alternate universe. For all the rest of us who would answer no to both, we're going to do something about it today, tomorrow, and in all the days to come, until we can all answer yes.
Francois de Brantes
Health Care Incentives Improvement Institute, Inc.