As physician incentives grow, so do ethical concerns

Is rewarding quality health care and aligning physicians’ financial incentives with the best interests of patients fundamentally unethical? J. Frank Wharam, MB, BCh, BAO, MPH, assistant professor of population medicine at Harvard Medical School in Boston, MA, co-led a Society of General Internal Medicine subcommittee that examined this question, and other ethical considerations with physician incentives.1

"Our committee felt that these are not fundamentally unethical," says Wharam. "In other words, it’s O.K. for better doctors to be paid more. Putting that into practice is a whole different story, however."

Nikola Biller-Andorno, MD, PhD, director of the Institute of Biomedical Ethics at the University of Zurich in Switzerland and visiting professor in the Division of Medical Ethics at Harvard Medical School in Boston, says that incentives imply manipulation and lead doctors to do what they would not have wanted to do, such as withholding treatment from a patient who might have needed it or providing an unneeded diagnostic intervention to a patient.

Other ethical issues, she says, include conflicts of interest withpossible negative effects on patient care, such ascherry-picking or "lemon-dropping" of certain patients. "Physicians become service providers, closely managed by administrators," she says. "At the same time, it is an illusion to believe that there is a way around incentives."

The challenge is to align incentives well with the goals of a health care institution, says Biller-Andorno, and to make sure they are implemented in an effective and ethically responsible way.

Bioethicists have multiple roles to play in this, says Biller-Andorno: They can do conceptual and empirical research on incentives and their effects on health care delivery; they can aid in the design and implementation of responsible incentive systems; and they can help educate students and young physicians and prepare them for conflicts of interests they might encounter in clinical practice and how to appropriately deal with them.

"Given the role of incentives as a key management tool, ACOs [Accountable Care Organizations] can be expected to rely quite heavily on them," Biller-Andorno says. "Hopefully, they will use them in an intelligent and responsible way that can avoid the pitfalls that come with aiming to influence professionals’ behavior."

Transition underway

The more that policies expand physician performance incentives, the greater the importance of considering ethical implications and the greater thelikelihood of ethically concerning effects if systems are not constructed carefully, says Wharam.

"In this transition, everything seems up in the air, confusing, and potentially perverse. But the change will be for the better, in all likelihood," says Thomas H. Lee, MD, on leave from his roles as professor of medicine at Harvard Medical School and the Harvard School of Public Health in Boston, MA, and current chief medical officer for Press Ganey. Lee says he is optimistic that health care is moving toward a system in which care is organized around meeting patients’ needs as efficiently as possible, rather than performing transactions and maximizing revenue from those transactions.

"What worries me most is that the primary definition of performance’ for ACOs is saving money, at least on the surface," says Lee. "In fact, I don’t think that is the case. You need market share regardless of the structure of your contracts. So you have to meet patients’ needs — or you will be out of business."

Here are some ethical concerns involving physician incentives:

• A careful and rigorousdefinition of quality must guide the creation of pay-for-performance systems.

"Defining health care quality is complex, and there isno consensus on a standard definition," says Wharam. Even if an accepteddefinition could be applied to all types of care,there would be nuanced differences in applying that definition tothe many types of specialists, stages of disease,and even types of patients.

"This raises the important question: How canwe design physician incentives to improve quality, when it is difficult to nail down and apply a precise definition of quality?" says Wharam.

Lee believes the greatest potential of ACOs is not saving money; it is meeting patients’ needs more effectively and also more efficiently than is currently done. "ACOs have the ability to be organized around meeting those needs," he says. "We just need to measure patients’ needs, so we can tell how we are doing in meeting them. We have the potential for much more ethical incentives than we currently have."

• There is a lack of proven safety and benefit of physician incentives.

Some studies have shown that pay-for-performance has either unintended consequences or no effect on patient outcomes.2-6

"In addition, current systems tend to assess and reward only easily measurable outcomes that do not represent the full spectrum of physician care," says Wharam. "This might sound like a minor problem, but it could cause concerning effects."

For example, if physicians are rewarded to improve diabetes care but not to address patients’ complaints, they might focus on diabetes to the detriment of investigating potentially serious symptoms.

"The challenge is implementing a system that rewards genuine quality, with minimal or no unintended consequences for patients, physicians, and society," says Wharam. The Society of General Internal Medicine subcommittee identified these four major steps toward designing incentives that are ethical and effective:

1. Current pay-for-performance systems should rapidly adopt safeguards to protect vulnerable populations.

For instance, additional compensation would be provided to doctors serving vulnerable populations. "Such patients are likely to fare more poorly, and thus reduce the apparent quality’ of the physicians’ care, and therefore compensation," Wharam explains.

2. Key stakeholders should develop consensus regarding their responsibilities in improving health care quality.

For example, to improve blood sugar control for patients with diabetes, physicians must recommend appropriate management strategies, practice groups must provide access to testing facilities, health insurers must facilitate affordable medications and tests, and patients must adhere to therapeutic plans.

3. Researchers and policy makers should develop valid and comprehensive quality measures.

Measures would account for individualized patient-physician goals, be based on the best available evidence, and minimize doctors’ administrative burden and expense. "Measures of physician quality should assess multiple domains, including accessibility, adherence to evidence-based and patient-centered care, and communication," says Wharam.

4. Researchers and policy makers should use a cautious evaluative approach to long-term development of financial incentive systems.

"Policy makers should implement carefully planned, small-scale pilot programs," says Wharam. "Benefits and adverse effects should be monitored, and wide-scale adoption should only occur after proof of safety and efficacy." 

References

1. Wharam JF, Paasche-Orlow MK, Farber NJ, et al. High quality care and ethical pay-for-performance: A Society of General Internal Medicine policy analysis. Gen Intern Med. 2009;24(7):854-859.

2. McDonald R, Roland M. Pay for performance in primary care in England and California: Comparison of unintended consequences. Ann Fam Med. 2009;7(2):121-127.

3. Gavagan TF, Du H, Saver BG, et al. Effect of financial incentives on improvement in medical quality indicators for primary care. J Am Board Fam Med. 2010;23(5):622-631.

4. Ryan AM, Blustein J, Casalino LP. Medicare’s flagship test of pay-for-performance did not spur more rapid quality improvement among low-performing hospitals.Health Affairs 2012;31(4):797-805.

5. Werner R, Dudley RA. "Medicare’s new hospital value-based purchasing program is likely to have only a small impact on hospital payments. Health Affairs 2012;31(9):1932-1940.

6. Werner R, Kolstad JT, Stuart EA, et al. The effect of pay-for-performance in hospitals: Lessons for quality improvement. Health Affairs 2011;30(4):690-698.

SOURCES

• Nikola Biller-Andorno, MD, PhD, Visiting Professor, Division of Medical Ethics, Harvard Medical School, Boston. Phone: (617) 487-6566. E-mail: nbiller@hsph.harvard.edu.
• Thomas H. Lee, MD, Chief Medical Officer, Press Ganey. Phone: (781) 295-5032. E-mail: Thomas.Lee@pressganey.com.
• J. Frank Wharam, MB, BCh, BAO, MPH, Assistant Professor of Medicine, Department of Population Medicine, Harvard Medical School, Boston, MA. Phone: (617) 509-9921. E-mail: jwharam@post.harvard.edu.