When physicians air their grievances on the New York Times op-ed page about how health care in the U.S. is undermined by dark forces, even skeptics should pay attention.
In a commentary last week called “How Medical Care Is Being Corrupted,” Drs. Pamela Hartzband and Jerome Groopman declared that “financial forces largely hidden from the public are beginning to corrupt care and undermine the bond of trust between doctors and patients. Insurers, hospital networks and regulatory groups have put in place both rewards and punishments that can powerfully influence your doctor’s decisions.”
A doctor’s treatment decisions, of course, should be based on what’s best for the patient, not what’s best for the infrastructure that’s supposed to enable the best care, not thwart it.
Hartzband and Groopman, who teach at Harvard Medical School, explain that cold numbers are poor drivers of quality care. What’s commonly called “metrics,” or numerical standards doctors are supposed to meet under contracts for medical care that reward “pay for performance,” are derived from whole population studies. That is, they’re generic standards for large groups of people, not measures to be applied to individual patients. People are different, and although metrics are useful in research and in shaping policy, they’re woefully inadequate in the assessment and support of a single human being.
Metrics, the writers say, do not account for patient preference, differing opinions or optimal practice for a given doctor-patient circumstance. Yet metrics are what the industry demands from providers if they expect financial support.
“[D]octors are rewarded for keeping their patients’ cholesterol and blood pressure below certain target levels,” Hartzband and Groopman cite as an example. “For some patients, this is good medicine, but for others the benefits may not outweigh the risks. Treatment with drugs such as statins can cause significant side effects, including muscle pain and increased risk of diabetes. Blood-pressure therapy to meet an imposed target may lead to increased falls and fractures in older patients.”
But physicians who meet designated targets for such values might receive not only a bonus from an insurer, but high ratings on the company’s website. Patients and potential patients generally would assume the high rating denotes high quality. The doctors who don’t meet the values are penalized financially through lower payments and “shamed” by lesser status on the website when, in fact, they might well be the superior practitioner, from the patient’s perspective.
It’s a great business growth model, and a lousy model for understanding human variables.
Doctors are only human; they’re not immune from the pressure to comply with the metrics. They might feel, say the writers, “pressured to withhold treatment that they feel is required or feel forced to recommend treatment whose risks may outweigh benefits.”
When you have a choice of drugs to treat a certain problem, there’s as much art as science in figuring out which is best for the patient. Genetics, living circumstances, age, gender, mobility … lots of things figure into the decision of who should get what drug.
Insurance companies don’t care. The writers decry how often larger co-payments are imposed on certain drugs as a way to dissuade doctors and patients from choosing higher-cost medications that, in the artful judgment of the people who know best, are the best match.
The writers offer WellPoint as an example. It’s one of the largest private underwriters of health care. It recently “outlined designated treatment pathways for cancer and announced that it would pay physicians an incentive of $350 per month per patient treated on the designated pathway.”
Bad call. As Hartzband and Groopman note, oncologists (cancer doctors) are hardly unified about what is optimal in cancer care. They regularly treat patients who deviate from treatment guidelines, and embracing that deviation is what drives one of the most significant recent advancements in cancer treatment — the concept of customized care, of targeted therapy.
It used to be that everybody with a certain kind of cancer, for example, got the same kind of chemotherapy drug in the same dose. Some did fine, some didn’t. But now cancer patients might get one of several kinds of chemotherapy drugs, they might be switched around or they might get a combination, depending on their genetic profile, the severity of side effects and other factors.
So, should oncologists make chemotherapy (or any drug) decisions based on these factors or based on adverse effects on payment? “Further,” the writers note, “some health care networks limit the ability of a patient to get a second opinion by going outside the network. The patient is financially penalized with large co-payments or no coverage at all. Additionally, the physician who refers the patient out of network risks censure from the network administration.”
How dare actuarial interests put doctors in a moral dilemma when a patient asks, as he or she should, “Is this treatment right for me?” What if the insurer covers the cost of one drug, but the doctor doesn’t believe it’s the “right” treatment?
Is health policy always and only about what’s best for a whole population? Can policy never bend to the individual good?
“We fear this approach can dangerously lead to ‘moral licensing,’” write Hartzband and Groopman — “the physician is able to rationalize forcing or withholding treatment, regardless of clinical judgment or patient preference, as acceptable for the good of the population.”
As medicine moves away from the old paternalism when patients never questioned, much less participated, in their care, it’s moving toward a new paternalism imposed by the insurers and regulators that control payment.
The writers propose that these powerful outside interests be subject to the same kind of transparency that the Physician Payments Sunshine Act established to expose (with mixed results) potential conflicts of interest by physicians with financial ties to pharmaceutical and device companies. “We propose a similar public website to reveal the hidden coercive forces that may specify treatments and limit choices through pressures on the doctor.
“Medical care is not just another marketplace commodity,” they conclude. “Physicians should never have an incentive to override the best interests of their patients.”