Yet another scandal regarding performance incentives in healthcare has surfaced. This time, the area is transplant medicine. It was reported that the demands by the Center for Medicare and Medicaid (CMS) for extremely low complication and death rates (with the threat of loss of accreditation and shutting down of the program) has led to thousands of kidneys and livers being discarded while tens of thousands languish in waiting lists, desperate to escape the living hell that is dialysis.
The fact is, if someone has a 75% chance of death in the next 6 months at baseline, and a 30% chance of dying if they receive a liver transplant, most will opt for the liver. But the competition to keep complication rates low means that surgeons would rather allow the donated organ to go to waste and let the patient die than take the risk of a hit to their program's statistics- and then be forced to close their program and be prevented from helping anyone at all. CMS has already folded, and relaxed their guidelines after a major paper published in the Journal of the American College of Surgeons forced their hand. But how could they not see this coming?
Major studies have found that the vaunted "report cards" comparing outcomes for Cardiothoracic surgery in New York have resulted in more individuals dying in ICUs instead of being helped by surgery- and increasing costs instead of decreasing them. In the UK, hospitals were paid based on how many of their patients were put on the Liverpool Pathway for the Dying- which led to a horrific fiasco where patients who may have lived were literally deprived of water and starved to death, and the families who tried to feed them prevented from doing so.
Pay for Performance, Value Based Purchasing, the so-called "Triple Aim" of increased quality, decreased costs, and improved population health- all of these concepts are not some benign corporate jargon that can be tolerated at worst and mildly beneficial at best. When patients' lives are on the line, there are very real consequences to using harsh and coercive extrinsic motivators in an attempt to get doctors and nurses to "improve" care.
The system is also gamed outrageously. When the Joint Commission passed a quality measure looking at "potentially preventable" deep vein thrombosis rates, many hospitals responded not by taking steps to prevent them, but by stopping screening programs to look for them in the first place. When it comes to transplant medicine, in doctor's lounges and internet forums whispered stories abound of patients with no prospect of recovery being given feeding and breathing tubes and other aggressive interventions- until the 1 year mark, after which their inevitable deaths will not count against the transplant program. Then the patients are promptly put on comfort care and allowed to expire. After the numbers began to be tracked, Obstetrician-Gynecologists began rampantly underestimating the blood loss during deliveries- 500 milliliters is both the formal definition of post-partum hemorrhage, and the actual volume of blood lost in up to 50% of normal deliveries.
The best way to help patients is to recognize that the overwhelming majority of doctors, nurses, and other allied health professionals want nothing more than to give the best care possible. With safer, intrinsic motivators that take advantage of this natural drive, care can be improved and patients helped. Per our profession's motto, "First, Do No Harm", perhaps the bureaucrats should take notice and adjust their preferred tactics.
But alas, they do not. The long standing fee-for-service payment system has it's own, terrible problems. But it is about to be replaced wholesale by the Merit-Based Incentive Payment system (MIPS) and Alternative Payment Models (APM), as part of the MACRA- the bill that reauthorized Medicare in 2015. I fear it will not be long before scandal after scandal of patients hurt by performance metrics begin to dominate our headlines.
The fact is, if someone has a 75% chance of death in the next 6 months at baseline, and a 30% chance of dying if they receive a liver transplant, most will opt for the liver. But the competition to keep complication rates low means that surgeons would rather allow the donated organ to go to waste and let the patient die than take the risk of a hit to their program's statistics- and then be forced to close their program and be prevented from helping anyone at all. CMS has already folded, and relaxed their guidelines after a major paper published in the Journal of the American College of Surgeons forced their hand. But how could they not see this coming?
Major studies have found that the vaunted "report cards" comparing outcomes for Cardiothoracic surgery in New York have resulted in more individuals dying in ICUs instead of being helped by surgery- and increasing costs instead of decreasing them. In the UK, hospitals were paid based on how many of their patients were put on the Liverpool Pathway for the Dying- which led to a horrific fiasco where patients who may have lived were literally deprived of water and starved to death, and the families who tried to feed them prevented from doing so.
Pay for Performance, Value Based Purchasing, the so-called "Triple Aim" of increased quality, decreased costs, and improved population health- all of these concepts are not some benign corporate jargon that can be tolerated at worst and mildly beneficial at best. When patients' lives are on the line, there are very real consequences to using harsh and coercive extrinsic motivators in an attempt to get doctors and nurses to "improve" care.
The system is also gamed outrageously. When the Joint Commission passed a quality measure looking at "potentially preventable" deep vein thrombosis rates, many hospitals responded not by taking steps to prevent them, but by stopping screening programs to look for them in the first place. When it comes to transplant medicine, in doctor's lounges and internet forums whispered stories abound of patients with no prospect of recovery being given feeding and breathing tubes and other aggressive interventions- until the 1 year mark, after which their inevitable deaths will not count against the transplant program. Then the patients are promptly put on comfort care and allowed to expire. After the numbers began to be tracked, Obstetrician-Gynecologists began rampantly underestimating the blood loss during deliveries- 500 milliliters is both the formal definition of post-partum hemorrhage, and the actual volume of blood lost in up to 50% of normal deliveries.
The best way to help patients is to recognize that the overwhelming majority of doctors, nurses, and other allied health professionals want nothing more than to give the best care possible. With safer, intrinsic motivators that take advantage of this natural drive, care can be improved and patients helped. Per our profession's motto, "First, Do No Harm", perhaps the bureaucrats should take notice and adjust their preferred tactics.
But alas, they do not. The long standing fee-for-service payment system has it's own, terrible problems. But it is about to be replaced wholesale by the Merit-Based Incentive Payment system (MIPS) and Alternative Payment Models (APM), as part of the MACRA- the bill that reauthorized Medicare in 2015. I fear it will not be long before scandal after scandal of patients hurt by performance metrics begin to dominate our headlines.
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