New Physician Oath: First, Reward Quality Care

Most physicians are good at following the creed laid out in the Hippocratic Oath to first, do no harm. But what comes second? For many physicians, that depends on the financial incentives that reward how they deliver care.

For instance, a recent study out of the University of California, Los Angeles, found that patient care performance ratings improved overall for 25 medical groups participating in pay-for-performance programs across California, but the success of the specific programs depended in large part on what was considered "performance."

When the incentives were aimed at addressing the quality of patient-clinician interactions, the overall experience of patient care tended to result in improved performance in three categories—physician communication, care coordination, and office staff interactions. However, when emphasis was placed on physician productivity, rather than clinical quality or patient experience, the improvements weren't as dramatic.

In fact, when financial incentives were paid directly to physicians—rather than being used more broadly—researchers found that putting too much emphasis on physician productivity actually had a negative impact on the experiences patients had when visiting their primary care provider.

In a way, this study is a microcosm of the larger healthcare reimbursement system. We've seen that paying physicians directly based on productivity can be harmful to the patient experience, because that's pretty much how the entire fee-for-service system works. In an essay in the New York Times, Sandeep Jauhar, MD, argues that hospital readmissions are a problem because physician revenue depends on keeping patients in the hospital.

He quoted a private practice internist as explaining the incentives like this: "I understand why hospitals want to cut down length-of-stay. But if I discharge a patient early, I don't get paid. It's O.K. if you have enough patients in the hospital, but if you don't, you sometimes have to drag out the stay. I don't like to do it, but sometimes you have to."

It is a callous and un-Hippocratic way of looking at medical care, but as Jauhar notes, "it is naïve to think that money cannot or should not be used to influence [physician] decisions."

President Obama has expressed a desire to change physician financial incentives—he was widely criticized when tried to explain the system with an example of a physician performing a tonsillectomy for financial reasons—but reform legislation has yet to address the issue head on.

Physician leaders don't have to wait for Washington to act. Many of the pay-for-performance programs like those studied by the UCLA researchers are happening at a more local level and being driven by private payers.

And many of the most direct financial incentives can be changed at the group level. Quite a few physician practices still pool revenues and allocate compensation to physicians based on elaborate formulas that are almost entirely driven by productivity (as measured by RVUs). Why not tweak the formulas to emphasize quality or patient experience?

Some already do this, but what's missing is a widespread change in practice compensation structures. Savvy leaders are making changes now because they perceive a top-down change coming relatively soon, and they want to be well-positioned in a new reimbursement system.

But finances aside, if its guiding principle really is to "first, do no harm," why would a practice still reward physicians for the quantity, rather than quality, of their care?