By Kip Sullivan
October 30, 2018
That was an excellent Quote of the Day, Don.
I want to emphasize the difference between what you and Alfie Kohn (the author of the NY Times essay) said, and what the RAND study authors said. You and Kohn said, “No more tinkering with P4P schemes, they don’t work, they make things worse.” The RAND study authors said, “Let’s keep tinkering, we can make P4P better.”
Here’s Kohn’s conclusion: “By now it should be clear that the trouble doesn’t lie with the type of reward, the schedule on which it’s presented, or any other detail of how it’s done. The problem is the outdated theory of motivation underlying the whole idea of treating people like pets — that is, saying: Do this, and you’ll get that.” In other words, the diagnosis underlying the entire P4P fad was wrong to begin with (it wasn’t merely “outdated”), ergo, the recommended solution — giving doctors little food pellets when they pull on the right lever and taking food pellets away when they fail to pull on the right lever — can’t work.
The RAND study is a useful contribution to the literature on what tended to be called P4P schemes from about 2000 to 2010, and since 2010 is more often called “value-based purchasing” (VBP) (The most important P4P/VBP schemes today are ACOs, medical homes, bundled payment, and the MIPS program.) The RAND study is useful because the authors actually went to the trouble of speaking to doctors — y’know, the people who treat patients who must cope with the useless feedback created by the proliferating VBP schemes imposed upon them by public and private insurers. It’s very rare to see a study that seeks to present the views of the creatures in the Skinner box created by VBP advocates over the last two decades (the Leapfrog Group, MedPAC, the Patient-centered Primary Care Collaborative, what used to be called the Institute of Medicine, the Robert Wood Johnson Foundation, Elliott Fisher, Stephen Shortell, Atul Gawande, Peter Orszag, Ezekiel Emanuel, members of both parties in Congress, etc.) The RAND study tells us that the creatures in the VBP Skinner box are confused and unhappy, and want out.
But the recommendations of the RAND study are ridiculous. They’re ridiculous because RAND has apparently totally ignored the research, accurately summed up by Kohn and Don, to wit, no amount of tinkering can fix a problem that was diagnosed incorrectly. (I say “apparently” because I have read only the summary of the RAND study.) RAND recommends merely:
- reducing the rate at which Congress, Medicare and the insurance industry gin up more VBP schemes,
- giving doctors some extra dollars to buy more IT hardware and software from Cerner and Epic so they can, in theory, make more sense of the white noise in the Skinner box, and
- provide more “understandable performance data.”
These pathetic recommendations reflect profound confusion about (a) the cause of high US health care costs (it’s our high prices caused by administrative waste and galloping consolidation, not excessive volume triggered by the FFS payment method) and (b) the solution (we need a true single-payer system, not Bernie’s bill or any other bill that doubles down on VBP nostrums).
How did the VBP buffs and RAND get so confused about the correct diagnosis of the American health care crisis and the correct response? Who told them per capita US health care costs are double those of the rest of the world because American doctors (and only American doctors) are motivated by greed and, therefore, routinely cave into the FFS incentive to order unnecessary services? Who told them physician “merit” or “efficiency” (their cost and quality) can be measured so accurately that the Masters of the Skinner Box can send doctors precise signals — more food pellets for you, fewer for you — that will accurately tell doctors when they’re being inefficient and when they’re failing to exercise good medical judgement?
Quote of the Day of October 29, 2018 — “Payment models are stuck in carrots and sticks”:
By Don McCanne, M.D.
Yesterday’s Quote of the Day message was too important to let it pass on without further comment. Government legislative and administrative officials and the policy community in both the public and private sector continue to lead us down the wrong pathway to reform. Their value-based purchasing models for health care reform (paying for value instead of volume) are failing because they are based on the incorrect assumption that physicians will repair our health care system if only they are presented with petty rewards or penalties. They completely miss the ethical and professional foundations of the science and art of medicine.
The RAND study is an important contribution because they actually looked at physicians and how they are responding to the current health care payment models. They showed that the models are increasingly complex, that they are changing at an accelerating pace, and that risk aversion is a consequence. The error that RAND makes is that they ignore their important findings and fall in line with the rest of policy community in recommending more of the same.
The article yesterday by Alfie Kohn shows us that the petty rewards or punishments of carrots or sticks, or success or failure of obtaining reward pellets from a Skinner box, “can never create a lasting commitment to an action or a value, and often they have exactly the opposite effect.” Value-based purchasing (MIPS, APMs, ACOs, etc.) reduces health care to a petty reward system that fails on goals of higher quality and lower costs, while creating harm, especially through physician burnout.
Yesterday’s Quote of the Day and today’s comments by Kip Sullivan present two rhetorical versions of the same concept just to be sure that everyone understands it: value-based purchasing is the wrong pathway to reform. Both will be posted on the PNHP website so that they will always be available to help educate others (http://www.pnhp.org/news/quote-of-the-day, Oct. 29 & 30, 2018).
After the midterm election the legislative proposals for Medicare for All will be undergoing refinement. We need to be sure that the architects are not deceived into thinking that the legislation needs updating by adding the flawed concepts of value-based purchasing. We cannot allow the ethics and professionalism of medicine to be replaced with the carrots, sticks, and Skinner box pellets of value-based purchasing.
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