Two Vignettes of Regulation: I

Bureaucratic regulation is very difficult. Even when the government sets up regulations, financial corporations manage to circumvent them without much more oversight than domesticate politicians are willing to provide.

In contrast, enormous resources are used to micromanage people without much power. This type of regulation is strangling education. Instead of single payer, ridiculous regulations of medicine are costing lives. Here is valuable testimony from a doctor writing in the new York Times.

"Not long ago, a colleague asked me for help in treating a patient with congestive heart failure who had just been transferred from another hospital. When I looked over the medical chart, I noticed that the patient, in his early 60s, was receiving an intravenous antibiotic every day. No one seemed to know why. Apparently it had been started in the emergency room at the other hospital because doctors there thought he might have pneumonia. But he did not appear to have pneumonia or any other infection. He had no fever. His white blood cell count was normal, and he wasn't coughing up sputum. His chest X-ray did show a vague marking, but that was probably just fluid in the lungs from heart failure."



"I ordered the antibiotic stopped - but not in time to prevent the patient from developing a severe diarrheal infection called C. difficile colitis, often caused by antibiotics. He became dehydrated. His temperature spiked to alarming levels. His white blood cell count almost tripled. In the end, with different antibiotics, the infection was brought under control, but not before the patient had spent almost two weeks in the hospital."

"The case illustrates a problem all too common in hospitals today: patients receiving antibiotics without solid evidence of an infection. And part of the blame lies with a program meant to improve patient care. The program is called pay for performance, P4P for short. Employers and insurers, including Medicare, have started about 100 such initiatives across the country. The general intent is to reward doctors for providing better care. For example, doctors receive bonuses if they prescribe ACE inhibitor drugs to patients with congestive heart failure. Hospitals get bonuses if they administer antibiotics to pneumonia patients in a timely manner."

"On the surface, this seems like a good idea: reward doctors and hospitals for quality, not just quantity. But even as it gains momentum, the initiative may be having untoward consequences. To get an inkling of the potential problems, one simply has to look at another quality-improvement program: surgical report cards. In the early 1990s, report cards were issued on surgeons performing coronary bypasses. The idea was to improve the quality of cardiac surgery by pointing out deficiencies in hospitals and surgeons; those who did not measure up would be forced to improve. But studies showed a very different result. A 2003 report by researchers at Northwestern and Stanford demonstrated there was a significant amount of "cherry-picking" of patients in states with mandatory report cards. In a survey in New York State, 63 percent of cardiac surgeons acknowledged that because of report cards, they were accepting only relatively healthy patients for heart bypass surgery. Fifty-nine percent of cardiologists said it had become harder to find a surgeon to operate on their most severely ill patients."

"Whenever you try to legislate professional behavior, there are bound to be unintended consequences. With surgical report cards, surgeons' numbers improved not only because of better performance but also because dying patients were not getting the operations they needed. Pay for performance is likely to have similar repercussions. Consider the requirement from Medicare that antibiotics be administered to a pneumonia patient within six hours of arriving at the hospital. The trouble is that doctors often cannot diagnose pneumonia that quickly. You have to talk to and examine a patient and wait for blood tests, chest X-rays and so on."

"Under P4P, there is pressure to treat even when the diagnosis isn't firm, as was the case with my patient with heart failure. So more and more antibiotics are being used in emergency rooms today, despite all-too-evident dangers like antibiotic-resistant bacteria and antibiotic-associated infections. I recently spoke with Dr. Charles Stimler, a senior health care quality consultant, about this problem. "We're in a difficult situation," he said. "We're introducing these things without thinking, without looking at the consequences. Doctors who wrote care guidelines never expected them to become performance measures." And the guidelines could have a chilling effect. "What about hospitals that stray from the guidelines in an effort to do even better?" Dr. Stimler asked.

"Should they be punished for trying to innovate? Will they have to take a hit financially until performance measures catch up with current research"?"

"The incentives for physicians raise problems too. Doctors are now being encouraged to voluntarily report to Medicare on 16 quality indicators, including prescribing aspirin and beta blocker drugs to patients who have suffered heart attacks and strict cholesterol and blood pressure control for diabetics. Those who perform well receive cash bonuses. But what to do about complex patients with multiple medical problems? Forty-eight percent of Medicare beneficiaries over 65 have at least three chronic conditions. Twenty-one percent have five or more. P4P quality measures are focused on acute illness. It isn't at all clear that they should be applied to elderly patients with multiple disorders who may have trouble keeping track of their medications."

"With P4P doling out bonuses, many doctors have expressed concern that they will feel pressured to prescribe "mandated" drugs, even to elderly patients who may not benefit, and to cherry-pick patients who can comply with pay-for-performance measures. And which doctor should be held responsible for meeting the quality guidelines? On average, Medicare patients see two primary-care physicians in any given year, and five specialists working in four practices. Care is widely dispersed, so it is difficult to assign responsibility to one doctor. If a doctor assumes responsibility for only a minority of her patients, then there is little financial incentive to participate in P4P. If she assumes too much responsibility, she may be unfairly blamed for any lapses in quality."

"Nor is it clear that pay for performance will actually result in better care, because it may end up benefiting mainly those physicians who already meet the guidelines. If they can collect bonuses by maintaining the status quo, what is the incentive to improve? Doctors have seldom been rewarded for excellence, at least not in any tangible way. In medical school, there were tests, board exams and lab practicals, but once you go into clinical practice, these traditional measures fall away. At first glance, pay for performance would seem to remedy this problem. But first its deep flaws must be addressed before patient care is compromised in unexpected ways."

Jauhar, Sandeep. 2008. "The Pitfalls of Linking Doctors' Pay to Performance." New York Times (8 September).

http://www.nytimes.com/2008/09/09/health/09essa.html