Out of Control Policy Blog

Medical Rationing Masquerading as Quality Care

Drs. Jerome Groopman and Pamela Hartzband wrote a column in yesterday's Wall Street Journal revealing a frightening new concept called "pay for performance" that Medicare bureaucrats are toying with to allegedly ensure proper patient care. Under it, Medicare would link doctor payments not to the services doctors provide, as is currently the case, but the quality of care they offer.

Sounds eminently sensible, right? And it would be if performance had something to do with patient satisfaction and actual clinical outcomes: whether, say -- and I don't want to go off on a limb here -- the patient actually lives or dies! That, however, is not the case. Rather, the quality of care is measured by a doctor's adherence to standardized protocols of care prescribed by a committee of experts.

Take diabetes, for instance, the good physicians note. In Massachusetts that has already institutionalized this new system, doctors are required to maintain normal levels of blood sugar in critically ill ICU patients.  If a physician allows blood sugar levels to rise above pre-ordained levels, he might even have to attend "re-education sessions" to be indoctrinated into the importance of the rule.

But maintaining normal blood sugar levels requires administering insulin. Yet in some patients it might well be better to tolerate higher-than-normal sugar levels rather than expose them to risk of too much insulin. Indeed, the New England Journal of Medicine last month published the results of a randomized study conducted on 6,000 patients that found that more patients died in the group where doctors were required to tightly control sugar levels compared to the one in which  they were allowed to follow a more flexible protocol.

The moral of the story? Medicine is more art than science and rigid rules that force doctors to ignore the trade offs in individual cases don't produce better overall outcomes - no matter how much bureaucratic backers of "performance based medicine" and "quality metrics" pretend otherwise.

Despite these emerging problems with this concept, the Obama administration is working with Congress to mandate that all Medicare payments be tied to "quality metrics." Why? Because ultimately, in my view, this concept has less to do with improving -- and and more to do with rationing -- care to control runaway costs. Standardized treatments, inevitably, cost less than unorthodox, experimental therapies - and pay-for-performance would incentivize the first and disincentivize - even penalize - the second.

In short, pay-for-performance is simply rationed care in sheep's clothing.

Welcome to 1984.

Shikha Dalmia is Senior Analyst


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