[Vision2020] New York City Ties Doctors’ Income to Quality of Care

[Art Deco]

 [image: The New York Times] <http://www.nytimes.com/>

------------------------------
January 11, 2013
New York City Ties Doctors’ Income to Quality of Care By ANEMONA
HARTOCOLLIS<http://topics.nytimes.com/top/reference/timestopics/people/h/anemona_hartocollis/index.html>

In a bold experiment in performance pay, complaints from patients at New
York City’s public hospitals and other measures of their care — like how
long before they are discharged and how they fare afterward — will be
reflected in doctors’ paychecks under a plan being negotiated by the
physicians and their hospitals.

The proposal represents a broad national push away from the traditional
model of rewarding doctors for the volume of services they order, a system
that has been criticized for promoting unnecessary treatment. In the wake
of changes laid out in the Affordable Care
Act<http://topics.nytimes.com/top/reference/timestopics/organizations/s/supreme_court/affordable_care_act/index.html>,
public and private hospitals are already preparing to have their income
tied partly to patient outcomes and cost containment, but the city’s plan
extends that financial incentive to the front line, the doctors directly
responsible for treatment. It also shows how the new law could change
longstanding relationships, giving more power to some of the poorest and
most vulnerable patients over doctors who run their care.

“I would expect that we’re going to see this become more and more prevalent
in compensation arrangements,” said Alan Aviles, president of the city’s Health
and Hospitals Corporation <http://www.nyc.gov/html/hhc/html/home/home.shtml>,
which runs the city’s 11 public hospitals and is the country’s largest
public health system, handling more than 1 million emergency room visits a
year.

The corporation’s plan would make doctors’ raises dependent on their
performance on quality measures. The details are being negotiated with the
doctors’ union, but both sides expect to reach an agreement that
incorporates the idea.

Still, doctors are hesitant, saying they could be penalized for conditions
they cannot control, including how clean the hospital floors are, the
attentiveness of nurses and the availability of beds.

And it is unclear whether performance incentives work in the medical world;
studies of similar programs in other countries indicate that doctors learn
to manipulate the system.

“The consequences in a complex system like a hospital for giving an
incentive for one little piece of behavior are virtually impossible to
foresee,” said Dr. David U. Himmelstein, professor of public health at the
City University of New York and a visiting professor at Harvard Medical
School, who has reviewed the literature on performance incentives. “There
are ways of gaming it without even outright lying that distort the meaning
of the measure.”

Over the next few years, the federal government will financially reward or
penalize hospitals based on how they perform on benchmarks that are
believed to be correlated with better patient outcomes. By aligning
doctors’ pay to the same benchmarks, city hospitals hope to perform well
enough to qualify for federal bonuses.

Under the proposal, bonuses of up to $59 million over the next three years
would be distributed to about 3,300 doctors, and would be given to
physicians as a group at each hospital, rather than as individuals, so that
even the worst doctor would benefit. They would amount to up to 2.5 percent
of salaries, which range from about $140,000 for entry-level primary-care
physicians to $400,000 for experienced specialists.

Dr. Bruce Siegel, president of the National Association of Public Hospitals
and Health Systems and a former head of the hospitals corporation, called
the plan “unprecedented for American public hospitals, in terms of scale,
in terms of moving us into a new model.”

Los Angeles County, which has the nation’s second-largest public health
system after New York, does not have anything similar, said Dr. Anish
Mahajan, director of system planning for the Los Angeles County Department
of Health Services <http://www.ladhs.org/wps/portal/>. “What an intriguing
idea,” Dr. Mahajan said. “That’s something we would hold out as a potential
thing we do in the future.”

Administrators at several private New York hospitals said they were
considering incorporating the federal benchmarks into their salary
structures, but have not yet done so on a significant scale.

The public hospital system has come up with 13 performance indicators.
Among them are how well patients say their doctors communicate with them,
how many patients with heart failure and pneumonia are readmitted within 30
days, how quickly emergency room patients go from triage to beds, whether
doctors get to the operating room on time and how quickly patients are
discharged.

Union officials said they were still fighting for wage increases, in
addition to performance bonuses. The union has also proposed expanding the
indicators to 20, including measures that would give doctors bonuses for
going to community meetings, giving lectures, getting training during work
hours, screening patients for obesity and counseling them to stop smoking.
It has also proposed excluding some patients — like developmentally
disabled patients, homeless people and those who have no place to go — from
incentives aimed at reducing the time patients spend in the hospital.

A union official, who spoke on the condition of anonymity so as not to
upset negotiations, said doctors considered the proposal demeaning. “To say
we’ll stick a carrot in front of you and therefore you’re going to be a
better doctor is a little disingenuous,” he said.

In a written statement, Dr. Barry Liebowitz, the president of the union,
the Doctors Council S.E.I.U., said it supported performance incentives in
theory, if they “will improve patient care.” But he called for a team
approach and hinted that the union would demand more doctors and support
staff.

The traditional physician incentive payments, tied to the income they
generate for hospitals, have been roundly blamed in recent years for
driving up costs. (The hospitals corporation had not used these incentives
but, in some cases, had required doctors’ groups to meet minimums for
billing.) Studies have found that they can lead to excessive testing and
“upcoding,” or diagnosing ailments as worse than they really are, to
justify more patient treatment and higher payments. Mr. Aviles said the
corporation’s plan would not tie payment to the volume or intensity of
care.

But Dr. Himmelstein said there were still hazards in the city’s plan. He
said that when primary-care doctors in England were offered bonuses based
on quality measures, they met virtually all of them in the first year,
suggesting either that quality improved or — the more likely explanation,
in his view — “they learned very quickly to teach to the test.”

“I think the most interesting finding is, things that were not measured, in
a few studies, appeared to have gotten a bit worse,” Dr. Himmelstein said.
For instance, patients were not as likely to stick with the same doctor,
possibly because they were encouraged to see whichever doctor was available
— speed was one quality measure — rather than the doctor who might know
them best. In another example, while the doctors reported that they had
controlled blood pressure in virtually all their patients, a random survey
showed no downward trend in blood pressure or strokes.

There could have been any number of ways of outsmarting the system, he
said: “If you take blood pressures three times and report the lowest, is
that lying or merely tipping the numbers in your favor?”

Dr. Himmelstein also said doctors could try to avoid the sickest and
poorest patients, who tend to have the worst outcomes and be the least
satisfied. But physicians within the public hospital system have little
ability to choose their patients, Mr. Aviles said. He added that he did not
expect the doctors to act so cynically because, “in the main, physicians
are here because they are attracted to that very mission of serving
everybody equally.”


-- 
Art Deco (Wayne A. Fox)
art.deco.studios at gmail.com
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