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Paying for performance

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Assessing the quality of care in general practice can mislead if it is not based on observations of that care. Asking doctors what they have done and judging quality on the basis of medical records is not good enough. 

The perils of judging what happens in the clinical setting on the basis of what doctors record is obvious in a study of a health care funding agency, in this case the NHS, ceasing to pay doctors for providing additional services it regarded as so desirable that for which it had previously provided incentive payments. 

A paper in the September 5 issue of the New England Journal of Medicine by five authors from the National Institute for Health and Care Excellence in the UK [N Engl J Med 2018; 379:948-957 or  www.nejm.org/doi/full/10.1056/NEJMsa180149] used electronic medical records from 2010 to 2017 in UK general practices to assess the effects of removing, in 2014, 12 incentives linked to 12 indicators and compared the outcomes for six indicators where the incentives were maintained.

The study was set in 2,819 English general practices with more than 20 million registered patients. There were big drops – 62 per cent – in records of indicators ‘related to lifestyle counselling for patients with hypertension’ when the incentives were withdrawn.  

The authors noted that reductions in the documentation of clinical processes varied widely among conditions – from a 6 per cent reduction for smoking counselling to a 30 per cent decrease in documenting BMI of 30 per cent among patients with mental illnesses.

The authors observe: “Several studies show that what is gained on incentive introduction is essentially lost on incentive withdrawal.”

But – and here’s the rub – what was gained?  The authors note: “The uncertainty about whether changes in the documentation [my italics] of care represent true changes in patient care.”

We do not know to what extent the reduced documentation of the incentivised clinical behaviours reflected reduced clinical care.

Other than the automatically updated markers (like lab tests) in the records, frequencies of other interventions were measured purely on their action being documented.

It is quite possible that the desired actions were still taking place at a similar rate, but were simply not documented. Ask any busy clinician about how record keeping can diminish when the day is long or when there’s an emergency. It is hardly surprising that documentary markers decrease after removal of incentive.

An example of the disconnect between the record and the action given in the paper is that of prescription of long-term contraceptives. Although the records suggested a fall in prescriptions after the withdrawal of the incentive, actual use assessed from other sources increased.

I hold to the view, based on long observation, including a five-year stint chairing a district health board in Sydney, that our health system would grind to a halt were it not for the altruism of health professionals, including doctors. Yes, getting the right mechanism for paying for health care matters intensely, and doctors are well paid, but creating the conditions where doctors can express and apply more altruism in the system may offer the best yield in clinical care. Worth an experiment, anyway.

Recently I read Out of the Wreckage: A New Politics for an Age of Crisis by British journalist George Monbiot. It is an exciting and optimistic book despite the prevailing uncertainties in many democracies.

A major thesis is that the distinctive human attribute which has led humanity to its current zenith, and which Monbiot considers to be critical to our approach to the future, is altruism – by which he means people looking out for others and caring for them. You can assess the strength of his argument for yourself or watch him on YouTube www.youtube.com/watch?v=uE63Y7srr_Y

If you consider that more needs to be done in improving health care, proceed cautiously with the idea of incentive payments.

Do not be beguiled in assessing their effectiveness by the documentation of process. Rather, measure their effects on actual care and outcomes. And when considering what doctors and other health professionals do day by day and how this might be strengthened, remember that altruism – doing caring things without concern about reward – still ranks highly on the scale of what motivates them.  This is why they do what they do. Make it easier for them.