Opinion
VIEWPOINT
Lara Goitein, MD Pulmonary and Critical Care Medicine, Christus St Vincent Regional Medical Center, Santa Fe, New Mexico.
Invited Commentary page 847
Corresponding Author: Lara Goitein, MD, Pulmonary and Critical Care Medicine, Christus St Vincent Regional Medical Center, 465 St Michaels Dr, Santa Fe, NM 87505 (lgoitein @gmail.com). jamainternalmedicine.com
The Argument Against Reimbursing Physicians for Value Since the time of Hippocrates, it has been assumed that a physician’s first obligation is to provide the best possible care to individual patients, without distortion by competing societal interests. 1 This once nearsacrosanct principle is being tested by the high costs of the health care in the United States, which increasingly threaten the economy. Because physicians control much of the delivery of health care, they have a natural role in helping to control health care costs. But historically, our society has been uneasy about assigning this role to physicians. When people are sick and helpless, do they really want their physicians to be influenced by costs, or do they need to believe that their physicians want only to serve them according to their medical needs? Physician organizations—under pressure to respond to growing costs—have increasingly asserted the profession's responsibility to take a role in allocating resources, for example, by developing efficient practice guidelines and participating in the development of health policy.2 However, their policy statements have also consistently reaffirmed the primacy of physicians’ responsibilities to individual patients. When these statements gingerly approach the topic of cost control at the bedside, they are careful to sidestep any conflict between physicians’ general advocacy for cost-effective care and their specific advocacy on behalf of individual patients. Under mounting pressure, the wall between these 2 different roles for physicians has largely held. Recently, however, the concept of reimbursing physicians for “value” in health care has breached the wall. Value is defined as the health outcomes achieved per dollar spent—essentially, the ratio of quality to cost. Value has taken center stage in health policy deliberations and has become the basis for major changes in physician reimbursement, led by the Centers for Medicare and Medicaid Services (CMS). In 2015, CMS pay-for-performance programs for hospitals and for physicians will include measures of both quality and cost, and proposed legislation would incorporate value into the Medicare physician fee schedule. Private insurers are following the lead of the federal government, and health care organizations are passing the risk to their physicians with internal pay-for-performance programs that reward both quality performance and lower costs. The concept of value has become popular precisely because it seems to offer a way that physicians can both take care of their patients and control costs for society without conflict of interest. The promise of value is harmony, or at least a method of resolution when there is tension between the 2 goals (the word value even carries virtuous overtones). As Lee has observed, “value is emerging as a concept—perhaps the only concept— that all stakeholders in healthcare embrace.”3 The term
value is often used loosely, blurring the components of quality and costs…almost as though value were a third entity, different from the ratio of its components. But in practice, the components may be separated, so that efforts to control costs remain but there is little attention to safeguarding of quality. Consider CMS’s new pay-for-performance program for physicians. Beginning in 2015, as part of the Affordable Care Act, Medicare payments to physicians will include an adjustment called the Value-Based Payment Modifier, which is based on 2 separate composite scores: 1 for quality, and 1 for costs. Although the formula links the 2 scores when the adjustment is determined, quality and costs may be considered quite separately at the point of care. For example, a physician could increase his or her reimbursement by concentrating on improving performance on several reported quality measures, while reducing spending broadly in other areas of care. It might be hoped that ensuring quality care would serve as an anchor to prevent excessive or misguided decreases in expenditures. But this is possible only if quality is accurately and comprehensively measured—a goal that remains elusive, despite impressive scholarship and efforts by CMS and its collaborators over the past decade. The relative weakness of the quality part of the determination of value is evident in the Valued-Based Payment Modifier program. As Berenson and Kaye4 have pointed out,theperformancemeasurescaptureanarrow,misleading picture of overall performance for any given physician and do not correlate with broader efforts to improve quality.5 Worse, reimbursing physicians based on performancemeasurescancausedetrimentaldistortionsincare, such as inordinate attention to the measures, the neglect of other important aspects of care, or the avoidance of sicker, poorer patients. In effect, then, Medicare will be paying physicians to decrease costs, without a reasonable guarantee that they will maintain quality. It is true that the goals of increasing the quality of care and decreasing costs often dovetail. For wellinsured patients, overtesting, overtreatment, and iatrogenic illness may be the biggest threats to the quality of health care—and in many geographic areas, higher spending is associated with worse health outcomes.5 Conversely, the few health organizations that achieve the best clinical outcomes do so at lower cost, by providing care that is standardized, integrated, and based on evidence. But it does not follow that rewarding institutions and physicians for decreasing spending will always encourage high quality. Although health care costs may be lowered by skilled, parsimonious care—or by systems that create intelligent, coordinated processes— they may also and more easily be lowered by indiscriminately stinting on care. In fact, substantial data suggest JAMA Internal Medicine June 2014 Volume 174, Number 6
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/30/2015
845
Opinion Viewpoint
that lower spending at the patient or hospital level is associated with poorer outcomes for patients.6 If physicians’ pay depends on considering costs as well as quality, each time a physician approaches a patient’s bedside, he or she may consider whether it is possible to provide less or cheaper care— whether, for example, a large decrease in cost is worth a small reduction in chance for diagnosis or cure. These choices will end up being based on the belief system (or susceptibility to financial incentives) of individual physicians. In aggregate, I believe, they undermine the single-minded commitment of doctors to their patients that has always been the hallmark of the profession. It may be that reimbursing physicians for value is better than the existing reimbursement system, in which ordinary fee-for-service payments encourage overtesting and overtreatment. But it should be noted that many of the proposals to incorporate value (including the Valued-Based Payment Modifier program) do not replace the feefor-service structure; they merely layer on additional incentives— adding to an increasingly complex array of financial considerations. Which incentives will prevail in influencing physicians’ behavior is not clear. One thing is certain, however: the influence of patients’ medical needs becomes ever more obscured. In my view, salary, without bonuses or withholds, is a better means to pay physicians because it sweeps away these layers of complexity. Reducing the financial incentives that lead to overtesting and overtreatment would in and of itself improve value. But if our society chooses to use pay-forperformance programs to reimburse physicians, then as physicians we should insist that these programs are based on quality measures that are unambiguously in our individual patients’ best interests. These quality measures could and should include those for avoiding unnecessary testing and treatment—but on the basis of quality alone.
Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002;136(3):243-246.
6. Joynt KE, Jha AK. The relationship between cost and quality: no free lunch. JAMA. 2012;307(10): 1082-1083.
Conflict of Interest Disclosures: None reported.
3. Lee TH. Putting the value framework to work. N Engl J Med. 2010;363(26):2481-2483.
REFERENCES
4. Berenson RA, Kaye DR. Grading a physician’s value: the misapplication of performance measurement. N Engl J Med. 2013;369(22):20792081.
7. Anderson GF, Squires DA. Measuring the US health care system: a cross-national comparison. Issue Brief (Commonw Fund). 2010;90:1-10.
ARTICLE INFORMATION Published Online: April 28, 2014. doi:10.1001/jamainternmed.2014.1063.
1. Angell M. Medicine: the endangered patient-centered ethic. Hastings Cent Rep. 1987;17 (1):S12-S13. 2. ABIM Foundation. American Board of Internal Medicine; ACP-ASIM Foundation. American College of Physicians-American Society of Internal Medicine; European Federation of Internal
846
Conceivably, the United States could reach a point of economic distress at which the public interest in cost control outweighs its interest in protecting physicians’ advocacy for their patients, but we are not there yet. We have not yet seriously addressed the waste in our profit-oriented system or sufficiently studied the successes in other countries that demonstrate better outcomes at considerably less cost—in other words, higher value.7 In contrast to the evidence provided by international models, there is notably little evidence that pay-for-performance can improve outcomes.8 Measuring and rewarding value is expensive, adding a large layer of bureaucracy and complexity to our already top-heavy system. Reimbursing for value fails by its own standard. It is unrealistic to expect that physicians should or could entirely avoid considering the costs of care. External budget constraints are common. But when we put on our white coats and approach the bedside, we should put aside considerations of costs—and financial incentives to do more or less—and remember our professional commitment to our patients. Many parties stand to gain from changing patients care, and financial incentives are constantly shifting. The cost of a treatment or test in any given year is as capricious as whether an insurer covers it, or the duration of a patent—and as merciless as what the market will bear. In this unstable and economically driven environment, it is critical that the patient retains one—just one—financially disinterested advocate. And in serving this role, we as physicians indirectly serve as a touchstone for wider public health and policy decisions. Value is not a panacea, or even new. It is simply a mathematical manipulation of two very old players: costs and quality. It does not absolve us of the need to consider the conflict inherent in asking physicians to base medical decisions partly on costs, however packaged.
5. Welch HG, Schwartz LM, Woloshin S. Overdiagnosed: Making People Sick in the Pursuit of Health. Boston, MA: Beacon Press; 2011.
8. Houle SK, McAlister FA, Jackevicius CA, Chuck AW, Tsuyuki RT. Does performance-based remuneration for individual health care practitioners affect patient care? a systematic review. Ann Intern Med. 2012;157(12):889-899.
JAMA Internal Medicine June 2014 Volume 174, Number 6
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/30/2015
jamainternalmedicine.com
VIEWPOINT
Lara Goitein, MD Pulmonary and Critical Care Medicine, Christus St Vincent Regional Medical Center, Santa Fe, New Mexico.
Invited Commentary page 847
Corresponding Author: Lara Goitein, MD, Pulmonary and Critical Care Medicine, Christus St Vincent Regional Medical Center, 465 St Michaels Dr, Santa Fe, NM 87505 (lgoitein @gmail.com). jamainternalmedicine.com
The Argument Against Reimbursing Physicians for Value Since the time of Hippocrates, it has been assumed that a physician’s first obligation is to provide the best possible care to individual patients, without distortion by competing societal interests. 1 This once nearsacrosanct principle is being tested by the high costs of the health care in the United States, which increasingly threaten the economy. Because physicians control much of the delivery of health care, they have a natural role in helping to control health care costs. But historically, our society has been uneasy about assigning this role to physicians. When people are sick and helpless, do they really want their physicians to be influenced by costs, or do they need to believe that their physicians want only to serve them according to their medical needs? Physician organizations—under pressure to respond to growing costs—have increasingly asserted the profession's responsibility to take a role in allocating resources, for example, by developing efficient practice guidelines and participating in the development of health policy.2 However, their policy statements have also consistently reaffirmed the primacy of physicians’ responsibilities to individual patients. When these statements gingerly approach the topic of cost control at the bedside, they are careful to sidestep any conflict between physicians’ general advocacy for cost-effective care and their specific advocacy on behalf of individual patients. Under mounting pressure, the wall between these 2 different roles for physicians has largely held. Recently, however, the concept of reimbursing physicians for “value” in health care has breached the wall. Value is defined as the health outcomes achieved per dollar spent—essentially, the ratio of quality to cost. Value has taken center stage in health policy deliberations and has become the basis for major changes in physician reimbursement, led by the Centers for Medicare and Medicaid Services (CMS). In 2015, CMS pay-for-performance programs for hospitals and for physicians will include measures of both quality and cost, and proposed legislation would incorporate value into the Medicare physician fee schedule. Private insurers are following the lead of the federal government, and health care organizations are passing the risk to their physicians with internal pay-for-performance programs that reward both quality performance and lower costs. The concept of value has become popular precisely because it seems to offer a way that physicians can both take care of their patients and control costs for society without conflict of interest. The promise of value is harmony, or at least a method of resolution when there is tension between the 2 goals (the word value even carries virtuous overtones). As Lee has observed, “value is emerging as a concept—perhaps the only concept— that all stakeholders in healthcare embrace.”3 The term
value is often used loosely, blurring the components of quality and costs…almost as though value were a third entity, different from the ratio of its components. But in practice, the components may be separated, so that efforts to control costs remain but there is little attention to safeguarding of quality. Consider CMS’s new pay-for-performance program for physicians. Beginning in 2015, as part of the Affordable Care Act, Medicare payments to physicians will include an adjustment called the Value-Based Payment Modifier, which is based on 2 separate composite scores: 1 for quality, and 1 for costs. Although the formula links the 2 scores when the adjustment is determined, quality and costs may be considered quite separately at the point of care. For example, a physician could increase his or her reimbursement by concentrating on improving performance on several reported quality measures, while reducing spending broadly in other areas of care. It might be hoped that ensuring quality care would serve as an anchor to prevent excessive or misguided decreases in expenditures. But this is possible only if quality is accurately and comprehensively measured—a goal that remains elusive, despite impressive scholarship and efforts by CMS and its collaborators over the past decade. The relative weakness of the quality part of the determination of value is evident in the Valued-Based Payment Modifier program. As Berenson and Kaye4 have pointed out,theperformancemeasurescaptureanarrow,misleading picture of overall performance for any given physician and do not correlate with broader efforts to improve quality.5 Worse, reimbursing physicians based on performancemeasurescancausedetrimentaldistortionsincare, such as inordinate attention to the measures, the neglect of other important aspects of care, or the avoidance of sicker, poorer patients. In effect, then, Medicare will be paying physicians to decrease costs, without a reasonable guarantee that they will maintain quality. It is true that the goals of increasing the quality of care and decreasing costs often dovetail. For wellinsured patients, overtesting, overtreatment, and iatrogenic illness may be the biggest threats to the quality of health care—and in many geographic areas, higher spending is associated with worse health outcomes.5 Conversely, the few health organizations that achieve the best clinical outcomes do so at lower cost, by providing care that is standardized, integrated, and based on evidence. But it does not follow that rewarding institutions and physicians for decreasing spending will always encourage high quality. Although health care costs may be lowered by skilled, parsimonious care—or by systems that create intelligent, coordinated processes— they may also and more easily be lowered by indiscriminately stinting on care. In fact, substantial data suggest JAMA Internal Medicine June 2014 Volume 174, Number 6
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/30/2015
845
Opinion Viewpoint
that lower spending at the patient or hospital level is associated with poorer outcomes for patients.6 If physicians’ pay depends on considering costs as well as quality, each time a physician approaches a patient’s bedside, he or she may consider whether it is possible to provide less or cheaper care— whether, for example, a large decrease in cost is worth a small reduction in chance for diagnosis or cure. These choices will end up being based on the belief system (or susceptibility to financial incentives) of individual physicians. In aggregate, I believe, they undermine the single-minded commitment of doctors to their patients that has always been the hallmark of the profession. It may be that reimbursing physicians for value is better than the existing reimbursement system, in which ordinary fee-for-service payments encourage overtesting and overtreatment. But it should be noted that many of the proposals to incorporate value (including the Valued-Based Payment Modifier program) do not replace the feefor-service structure; they merely layer on additional incentives— adding to an increasingly complex array of financial considerations. Which incentives will prevail in influencing physicians’ behavior is not clear. One thing is certain, however: the influence of patients’ medical needs becomes ever more obscured. In my view, salary, without bonuses or withholds, is a better means to pay physicians because it sweeps away these layers of complexity. Reducing the financial incentives that lead to overtesting and overtreatment would in and of itself improve value. But if our society chooses to use pay-forperformance programs to reimburse physicians, then as physicians we should insist that these programs are based on quality measures that are unambiguously in our individual patients’ best interests. These quality measures could and should include those for avoiding unnecessary testing and treatment—but on the basis of quality alone.
Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002;136(3):243-246.
6. Joynt KE, Jha AK. The relationship between cost and quality: no free lunch. JAMA. 2012;307(10): 1082-1083.
Conflict of Interest Disclosures: None reported.
3. Lee TH. Putting the value framework to work. N Engl J Med. 2010;363(26):2481-2483.
REFERENCES
4. Berenson RA, Kaye DR. Grading a physician’s value: the misapplication of performance measurement. N Engl J Med. 2013;369(22):20792081.
7. Anderson GF, Squires DA. Measuring the US health care system: a cross-national comparison. Issue Brief (Commonw Fund). 2010;90:1-10.
ARTICLE INFORMATION Published Online: April 28, 2014. doi:10.1001/jamainternmed.2014.1063.
1. Angell M. Medicine: the endangered patient-centered ethic. Hastings Cent Rep. 1987;17 (1):S12-S13. 2. ABIM Foundation. American Board of Internal Medicine; ACP-ASIM Foundation. American College of Physicians-American Society of Internal Medicine; European Federation of Internal
846
Conceivably, the United States could reach a point of economic distress at which the public interest in cost control outweighs its interest in protecting physicians’ advocacy for their patients, but we are not there yet. We have not yet seriously addressed the waste in our profit-oriented system or sufficiently studied the successes in other countries that demonstrate better outcomes at considerably less cost—in other words, higher value.7 In contrast to the evidence provided by international models, there is notably little evidence that pay-for-performance can improve outcomes.8 Measuring and rewarding value is expensive, adding a large layer of bureaucracy and complexity to our already top-heavy system. Reimbursing for value fails by its own standard. It is unrealistic to expect that physicians should or could entirely avoid considering the costs of care. External budget constraints are common. But when we put on our white coats and approach the bedside, we should put aside considerations of costs—and financial incentives to do more or less—and remember our professional commitment to our patients. Many parties stand to gain from changing patients care, and financial incentives are constantly shifting. The cost of a treatment or test in any given year is as capricious as whether an insurer covers it, or the duration of a patent—and as merciless as what the market will bear. In this unstable and economically driven environment, it is critical that the patient retains one—just one—financially disinterested advocate. And in serving this role, we as physicians indirectly serve as a touchstone for wider public health and policy decisions. Value is not a panacea, or even new. It is simply a mathematical manipulation of two very old players: costs and quality. It does not absolve us of the need to consider the conflict inherent in asking physicians to base medical decisions partly on costs, however packaged.
5. Welch HG, Schwartz LM, Woloshin S. Overdiagnosed: Making People Sick in the Pursuit of Health. Boston, MA: Beacon Press; 2011.
8. Houle SK, McAlister FA, Jackevicius CA, Chuck AW, Tsuyuki RT. Does performance-based remuneration for individual health care practitioners affect patient care? a systematic review. Ann Intern Med. 2012;157(12):889-899.
JAMA Internal Medicine June 2014 Volume 174, Number 6
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/30/2015
jamainternalmedicine.com
