Health Policy
Perspective
Balancing Incentives and Professionalism in Health Care Payment Reform By Barry Meisenberg, MD
As to the honor and conscience of doctors, they have as much as any other class of men, no more and no less. And what other men dare pretend to be impartial where they have a strong pecuniary interest on one side?—George Bernard Shaw (preface to The Doctor’s Dilemma, 1911)1 The great Irish social critic George Bernard Shaw was a cynic, at least when he reflected on the medical profession. Shaw was scandalized that physicians would not admit to their pecuniary self-interests in the rendering of medical advice. He ridiculed the physicians of his day for their stalwart belief that their own sense of honor was purer than that of other classes of people. Shaw cynically imagined surgeons routinely asking themselves, “Could I not make a better use of a pocketful of guineas than this man is making of his leg?”1(p10) Shaw’s view that doctors’ advice and mode of practice is dominated by self-interest is astride in the world today even if expressed with considerably less wit. Modern day cynics, (they prefer to be recognized as ‘realists’), survey the wreckage of the American health care system, ascribe it to perverse incentives for greater utilization, and devise new models that “align incentives,” “pay for performance,” “reward value,” and “share savings.” They argue that we need to replace the old incentives with newer ones that would continue to benefit physicians but also benefit society by more constrained expenditures. The practice pattern of oncologists is a particular focus of such efforts. Before condemning cynical realists, we should admit that there is much evidence to shape their world view. Self-interested medical decision making leading to excessive utilization is found in analyses of practice patterns of many medical specialties,2-4 most recently in the selection of more profitable ways of delivering prostatic radiation therapy when urologists own radiation facilities.5 Collectively, these analyses recall Shaw’s observation about physicians that “The human conscience can subsist on very questionable food.”1(p9) Beyond these examples, there are cases of individual physician self-interest crossing the line into criminality and even assault by medical intervention.6 The cynical realists believe that physician behaviors will be determined by financial incentives, and thus they labor to reconfigure physician incentives. The newly incented physicians are to be deployed as highly trained guardians of utilization. But to rely on financial incentives alone while disregarding that other powerful motivator of physician behavior, professionalism, is to doom the reforms before they begin in earnest. Such strategies ignore established concepts of psychology that Copyright © 2014 by American Society of Clinical Oncology
make important distinctions between intrinsic and extrinsic motivations; the former arising from an inherent interest or value, the latter arising from external forces or compulsion. Extrinsic motivation most often is a paler and weaker form of motivation.7 Professionalism is a form of intrinsic motivation, awarding to its practitioner its own form of joy and satisfaction. It may surprise some cynical realists that the pulse of professionalism is still detectable in the physician corpus. Palpate carefully and you can find it in the scores of hours and thousands of dollars spent by physicians exceeding the minimum requirements for continuing medical education; in the care devoted to the uninsured, the minimally insured, and the impoverished; in the volitional attendance at tumor boards, case conferences, morbidity and mortality rounds, each designed to sharpen clinical skills and improve patient welfare. There is ample room under the intrinsic motivation of professionalism umbrella to guide physicians to be better stewards of limited resources and work to reduce waste. Professionalism was linked to cost containment more than a decade ago, when the American Board of Internal Medicine restated the ideals of professionalism in the form of 10 commitments, one of which read, “While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources.”8 The ethics of medical spending were discussed in a 2001 essay by Milton Weinstein,9 who elaborated on the existing concept of a finite “medical commons.” The medical commons, shared by all physicians, consists of the finite resources available for medical care. Weinstein also foresaw an irreconcilable tension between the traditional ethical concepts that promote unlimited care in the service of a single patient and the modern realities of harms created by that unlimited care. One can envision, then, that efforts to reduce wasteful spending as an effort to make more room in the medical commons. Indeed, an appeal to medical professionalism is at the core of the Choosing Wisely campaign of the American Board of Internal Medicine Foundation and its public interest partners.10 This campaign is designed to provoke dialogue about tests, procedures, and therapies that have been identified as being of small or no benefit. Beyond cost, many of the identified tests, procedures, and therapies have the potential to cause harm. Medical misadventure from unnecessary tests and procedures is a familiar narrative, whether from overuse of antibiotics or the risk of false positives from superfluous medical imaging. Preventing such harms should be one of the highest ethical
N O V E M B E R 2014
•
jop.ascopubs.org
363
Information downloaded from jop.ascopubs.org and provided by at UNIV CALIFORNIA SAN DIEGO on June 6, 2015 from 132.239.1.231 Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
Anne Arundel Medical Center, DeCesaris Cancer Institute, Annapolis, MD
Barry Meisenberg
nancial toxicity. The ethical argument to be cost conscious is strengthened by the awareness of the unseen victims of high medical costs: those who will experience a lifetime of higher taxes, lower wages, higher insurance costs, and shrinkage of insurance benefits as a result of society’s inability to limit medical spending. To practice non– cost conscious medicine is to contribute to the injury of these unseen victims. But even when considering only the individual patient, it is the hallmark of professionalism, not the absence of it, to be keenly aware of costs, to gauge the risks of false positives and strict necessity in test ordering, and to give equal consideration to both the potential for harm and the potential for benefit in all that we do. The inspiration to reform medical care must not come solely from the cynical realist heirs of Shaw. Rather, let us listen to what Abraham Lincoln termed the “better angels of our nature.”16 Author’s Disclosures of Potential Conflicts of Interest The author indicated no potential conflicts of interest. Corresponding author: Barry Meisenberg, MD, Anne Arundel Medical Center DeCesaris Cancer Institute, 2001 Medical Parkway, Donner Pavilion, Annapolis, MD 21401; e-mail: [email protected].
DOI: 10.1200/JOP.2014.001491; published online ahead of print at jop.ascopubs.org on June 17, 2014.
References 1. Shaw GB: The Doctor’s Dilemma: A Tragedy (Laurence DH, ed). London, UK, Penguin, 1957
9. Weinstein MC: Should physicians be gatekeepers of medical resources? J Med Ethics 27:268-274, 2001
2. Yip WC: Physician response to Medicare fee reductions: Changes in the volume of coronary artery bypass graft (CABG) surgeries in the Medicare and private sectors. J Health Econ 17:675-699, 1998
10. Cassel CK, Guest JA: Choosing wisely-helping physicians and patients make smart decisions about their care. JAMA 307:1801-1802, 2012
3. McGuire TG: Physician response to fee changes with multiple payers. J Health Econ 10:1385-1410, 1991 4. Gruber J, Kim J, Mayzlin D: Physician fees and procedure intensity: The case of cesarean delivery. J Health Econ 18:473-490, 1999
11. Berwick DM, Hackbarth AD: Eliminating waste in US health care. JAMA 307:1513-1516, 2012 12. Ubel PA, Abernethy AP, Zafar SY: Full disclosure-out of pocket costs as side effects. N Engl J Med 369:1484-1486, 2013
5. Mitchell JM: Urologists’ use of intensity-modulated radiation therapy for prostate cancer. N Engl J Med 369:1629-1637, 2013
13. Dusetzina SB, Winn AN, Abel GA, et al: Cost sharing and adherence to tyrosine kinase inhibitors for patients with chronic myelogenous leukemia. J Clin Oncol 32:306-311, 2014
6. Harris G: Doctor Faces Suits over Cardiac Stents. New York Times. December 5, 2010. http://www.nytimes.com/2010/12/06/health/06stent.html?pagewanted⫽all&_ r⫽1&
14. Kelly RJ, Smith TJ: Delivering maximum clinical benefit at an affordable price: Engaging stakeholders in cancer care. Lancet Oncol [epub ahead of print on February 14, 2014]
7. Ryan RM, Deci EL: Intrinsic and extrinsic motivations: Classic definitions and new directions. Contemp Educ Psychol 25:54-67, 2000
15. Rosenbaum L, Lamas D: Cents and sensitivity-teaching physicians to think about costs. N Engl J Med 367:99-101, 2012
8. ABIM Foundation: American Board of Internal Medicine Foundation. Medical professionalism in the new millennium: A physician charter. Ann Intern Med 136: 243-246, 2002
16. Lincoln A: Speeches and writings, 1859-1865: Speeches, Letters, and Miscellaneous Writings, Presidential Messages and Proclamations (Fehrenbacher DE, Basler RP, eds). New York, NY, Literary Classics of the United States, 1989
364
JOURNAL
OF
ONCOLOGY PRACTICE
•
V O L . 10, I S S U E 6
Copyright © 2014 by American Society of Clinical Oncology
Information downloaded from jop.ascopubs.org and provided by at UNIV CALIFORNIA SAN DIEGO on June 6, 2015 from 132.239.1.231 Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
priorities of the medical profession, not something we do only if we share the cost savings. The Choosing Wisely lists represent only a small part of the mountain of wasteful spending estimated to be in the range of 21% to 47% of all health care spending ($558-$1,263 billion) in the United States in 2011.11 Discussions about the impact of medical costs on both the individual patient and society at large are no longer proscribed. Indeed, they are welcomed by an increasing number of patients who may have substantial outof-pocket costs. It has been recently powerfully argued that protecting patients from “financial toxicity”—the risk of financial ruin from medical testing or treatment—is an important professional responsibility.12 The experienced oncologist knows well the high burden that medical costs have on patients and families, resulting in lack of adherence to treatment.13 The professional responsibility of oncologists to consider costs was recently emphasized by Kelly and Smith, who cited three main areas: end-of-life care, use of imaging, and chemotherapy choices.14 No practicing oncologist can claim to be unaware of the issues that these authors have highlighted. Some have argued that sacrificing the desires and needs of the individual to the needs of society is a step down the road to perdition.15 The point is arguable and possibly not resolvable, as Weinstein points out.9 But it should be openly recognized that the harms of high medical costs extend beyond the individual patient in our examination rooms who experiences fi-
Perspective
Balancing Incentives and Professionalism in Health Care Payment Reform By Barry Meisenberg, MD
As to the honor and conscience of doctors, they have as much as any other class of men, no more and no less. And what other men dare pretend to be impartial where they have a strong pecuniary interest on one side?—George Bernard Shaw (preface to The Doctor’s Dilemma, 1911)1 The great Irish social critic George Bernard Shaw was a cynic, at least when he reflected on the medical profession. Shaw was scandalized that physicians would not admit to their pecuniary self-interests in the rendering of medical advice. He ridiculed the physicians of his day for their stalwart belief that their own sense of honor was purer than that of other classes of people. Shaw cynically imagined surgeons routinely asking themselves, “Could I not make a better use of a pocketful of guineas than this man is making of his leg?”1(p10) Shaw’s view that doctors’ advice and mode of practice is dominated by self-interest is astride in the world today even if expressed with considerably less wit. Modern day cynics, (they prefer to be recognized as ‘realists’), survey the wreckage of the American health care system, ascribe it to perverse incentives for greater utilization, and devise new models that “align incentives,” “pay for performance,” “reward value,” and “share savings.” They argue that we need to replace the old incentives with newer ones that would continue to benefit physicians but also benefit society by more constrained expenditures. The practice pattern of oncologists is a particular focus of such efforts. Before condemning cynical realists, we should admit that there is much evidence to shape their world view. Self-interested medical decision making leading to excessive utilization is found in analyses of practice patterns of many medical specialties,2-4 most recently in the selection of more profitable ways of delivering prostatic radiation therapy when urologists own radiation facilities.5 Collectively, these analyses recall Shaw’s observation about physicians that “The human conscience can subsist on very questionable food.”1(p9) Beyond these examples, there are cases of individual physician self-interest crossing the line into criminality and even assault by medical intervention.6 The cynical realists believe that physician behaviors will be determined by financial incentives, and thus they labor to reconfigure physician incentives. The newly incented physicians are to be deployed as highly trained guardians of utilization. But to rely on financial incentives alone while disregarding that other powerful motivator of physician behavior, professionalism, is to doom the reforms before they begin in earnest. Such strategies ignore established concepts of psychology that Copyright © 2014 by American Society of Clinical Oncology
make important distinctions between intrinsic and extrinsic motivations; the former arising from an inherent interest or value, the latter arising from external forces or compulsion. Extrinsic motivation most often is a paler and weaker form of motivation.7 Professionalism is a form of intrinsic motivation, awarding to its practitioner its own form of joy and satisfaction. It may surprise some cynical realists that the pulse of professionalism is still detectable in the physician corpus. Palpate carefully and you can find it in the scores of hours and thousands of dollars spent by physicians exceeding the minimum requirements for continuing medical education; in the care devoted to the uninsured, the minimally insured, and the impoverished; in the volitional attendance at tumor boards, case conferences, morbidity and mortality rounds, each designed to sharpen clinical skills and improve patient welfare. There is ample room under the intrinsic motivation of professionalism umbrella to guide physicians to be better stewards of limited resources and work to reduce waste. Professionalism was linked to cost containment more than a decade ago, when the American Board of Internal Medicine restated the ideals of professionalism in the form of 10 commitments, one of which read, “While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources.”8 The ethics of medical spending were discussed in a 2001 essay by Milton Weinstein,9 who elaborated on the existing concept of a finite “medical commons.” The medical commons, shared by all physicians, consists of the finite resources available for medical care. Weinstein also foresaw an irreconcilable tension between the traditional ethical concepts that promote unlimited care in the service of a single patient and the modern realities of harms created by that unlimited care. One can envision, then, that efforts to reduce wasteful spending as an effort to make more room in the medical commons. Indeed, an appeal to medical professionalism is at the core of the Choosing Wisely campaign of the American Board of Internal Medicine Foundation and its public interest partners.10 This campaign is designed to provoke dialogue about tests, procedures, and therapies that have been identified as being of small or no benefit. Beyond cost, many of the identified tests, procedures, and therapies have the potential to cause harm. Medical misadventure from unnecessary tests and procedures is a familiar narrative, whether from overuse of antibiotics or the risk of false positives from superfluous medical imaging. Preventing such harms should be one of the highest ethical
N O V E M B E R 2014
•
jop.ascopubs.org
363
Information downloaded from jop.ascopubs.org and provided by at UNIV CALIFORNIA SAN DIEGO on June 6, 2015 from 132.239.1.231 Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
Anne Arundel Medical Center, DeCesaris Cancer Institute, Annapolis, MD
Barry Meisenberg
nancial toxicity. The ethical argument to be cost conscious is strengthened by the awareness of the unseen victims of high medical costs: those who will experience a lifetime of higher taxes, lower wages, higher insurance costs, and shrinkage of insurance benefits as a result of society’s inability to limit medical spending. To practice non– cost conscious medicine is to contribute to the injury of these unseen victims. But even when considering only the individual patient, it is the hallmark of professionalism, not the absence of it, to be keenly aware of costs, to gauge the risks of false positives and strict necessity in test ordering, and to give equal consideration to both the potential for harm and the potential for benefit in all that we do. The inspiration to reform medical care must not come solely from the cynical realist heirs of Shaw. Rather, let us listen to what Abraham Lincoln termed the “better angels of our nature.”16 Author’s Disclosures of Potential Conflicts of Interest The author indicated no potential conflicts of interest. Corresponding author: Barry Meisenberg, MD, Anne Arundel Medical Center DeCesaris Cancer Institute, 2001 Medical Parkway, Donner Pavilion, Annapolis, MD 21401; e-mail: [email protected].
DOI: 10.1200/JOP.2014.001491; published online ahead of print at jop.ascopubs.org on June 17, 2014.
References 1. Shaw GB: The Doctor’s Dilemma: A Tragedy (Laurence DH, ed). London, UK, Penguin, 1957
9. Weinstein MC: Should physicians be gatekeepers of medical resources? J Med Ethics 27:268-274, 2001
2. Yip WC: Physician response to Medicare fee reductions: Changes in the volume of coronary artery bypass graft (CABG) surgeries in the Medicare and private sectors. J Health Econ 17:675-699, 1998
10. Cassel CK, Guest JA: Choosing wisely-helping physicians and patients make smart decisions about their care. JAMA 307:1801-1802, 2012
3. McGuire TG: Physician response to fee changes with multiple payers. J Health Econ 10:1385-1410, 1991 4. Gruber J, Kim J, Mayzlin D: Physician fees and procedure intensity: The case of cesarean delivery. J Health Econ 18:473-490, 1999
11. Berwick DM, Hackbarth AD: Eliminating waste in US health care. JAMA 307:1513-1516, 2012 12. Ubel PA, Abernethy AP, Zafar SY: Full disclosure-out of pocket costs as side effects. N Engl J Med 369:1484-1486, 2013
5. Mitchell JM: Urologists’ use of intensity-modulated radiation therapy for prostate cancer. N Engl J Med 369:1629-1637, 2013
13. Dusetzina SB, Winn AN, Abel GA, et al: Cost sharing and adherence to tyrosine kinase inhibitors for patients with chronic myelogenous leukemia. J Clin Oncol 32:306-311, 2014
6. Harris G: Doctor Faces Suits over Cardiac Stents. New York Times. December 5, 2010. http://www.nytimes.com/2010/12/06/health/06stent.html?pagewanted⫽all&_ r⫽1&
14. Kelly RJ, Smith TJ: Delivering maximum clinical benefit at an affordable price: Engaging stakeholders in cancer care. Lancet Oncol [epub ahead of print on February 14, 2014]
7. Ryan RM, Deci EL: Intrinsic and extrinsic motivations: Classic definitions and new directions. Contemp Educ Psychol 25:54-67, 2000
15. Rosenbaum L, Lamas D: Cents and sensitivity-teaching physicians to think about costs. N Engl J Med 367:99-101, 2012
8. ABIM Foundation: American Board of Internal Medicine Foundation. Medical professionalism in the new millennium: A physician charter. Ann Intern Med 136: 243-246, 2002
16. Lincoln A: Speeches and writings, 1859-1865: Speeches, Letters, and Miscellaneous Writings, Presidential Messages and Proclamations (Fehrenbacher DE, Basler RP, eds). New York, NY, Literary Classics of the United States, 1989
364
JOURNAL
OF
ONCOLOGY PRACTICE
•
V O L . 10, I S S U E 6
Copyright © 2014 by American Society of Clinical Oncology
Information downloaded from jop.ascopubs.org and provided by at UNIV CALIFORNIA SAN DIEGO on June 6, 2015 from 132.239.1.231 Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
priorities of the medical profession, not something we do only if we share the cost savings. The Choosing Wisely lists represent only a small part of the mountain of wasteful spending estimated to be in the range of 21% to 47% of all health care spending ($558-$1,263 billion) in the United States in 2011.11 Discussions about the impact of medical costs on both the individual patient and society at large are no longer proscribed. Indeed, they are welcomed by an increasing number of patients who may have substantial outof-pocket costs. It has been recently powerfully argued that protecting patients from “financial toxicity”—the risk of financial ruin from medical testing or treatment—is an important professional responsibility.12 The experienced oncologist knows well the high burden that medical costs have on patients and families, resulting in lack of adherence to treatment.13 The professional responsibility of oncologists to consider costs was recently emphasized by Kelly and Smith, who cited three main areas: end-of-life care, use of imaging, and chemotherapy choices.14 No practicing oncologist can claim to be unaware of the issues that these authors have highlighted. Some have argued that sacrificing the desires and needs of the individual to the needs of society is a step down the road to perdition.15 The point is arguable and possibly not resolvable, as Weinstein points out.9 But it should be openly recognized that the harms of high medical costs extend beyond the individual patient in our examination rooms who experiences fi-
