Health Reform and Pay-for—Performance, Not So Fast,Macduff!

Lay on, Macduff
And damn’d be him that first cries,”Hold enough!

Shakespeare, Macbeth

In Macbeth, Macduff symbolizes virtue, which should be rewarded but does not always win in the end. The rigid regulators of practice rectitude and worshippers of computer-guided best practice protocols must have been taken back when they read the negative results of a nine year study of 470,000 hypertensive British patients treated by doctors rewarded through pay-for-performance guidelines.

Doctor Incentives Don't Improve Patient care - study

“LONDON, January 26, (Reuters) - Paying doctors financial rewards to meet targets for improving the care of patients made no discernible difference to the health or treatment of people with high blood pressure, a study has found.”

“The findings suggest governments and health insurers across the world may be wasting billions of dollars on doctor incentive schemes but getting no improvement in patient care, researchers who conducted the study said.”

“Researchers from Britain, the United States and Canada assessed the impact of incentivised targets on quality of care and health outcomes in around 470,000 British patients with hypertension and found that they had no impact on rates of heart attacks, kidney failure, stroke or death.”

"No matter how we looked at the numbers, the evidence was unmistakable; by no measure did pay-for-performance benefit patients with hypertension," said Brian Serumaga of Britain's Nottingham University, who led the research.”

What? You mean doctors being paid to follow health reform quality improvement rules may be wasting taxpayer money.

What? You mean outcomes don’t improve.

The neutral consequences of pay-for-performance must come as a shock to those who believe doctors are primarily at fault for the bad performance and shoddy outcomes of health systems around the world.

I would like to humbly suggest there may be a reason for these disappointing results , namely. that doctors cannot change patient behavior once patients leave the office to return to their former lifestyles and to the habits that lead to hypertension in the first place. Patients may continue to have stress, to drink too much, to eat high salt diets, to exercise too little, and to not take their medications appropriately or at all. Genetics play a central role in clinical destinies as well.

There are no prescriptions that can be written or outpatient rules that can be enforced by doctors that will change basic human behavior and habits developed over a lifetime. Perhaps outcomes could be improved through intervention and surveillance by outpatient professionals – nurses, social workers, trained volunteers or visiting doctors- or through technological sensors measuring blood pressures and lipids- but human freedom and the choice to behave as one wishes is another ball of wax beyond the pall of office-based physicians.