Psychiatrists have long recognized that rewarding desired behavior is far
more effective than punishing undesired ones. Judging from a recent New York
Times editorial ["Not Paying for Medical Errors," August 21], some editors,
journalists and government bureaucrats have not accepted this axiom.
The editorial reports that "Medicare has announced that it will soon stop
paying hospitals for the extra costs of treating certain patients whose
illnesses are compounded by preventable errors" and goes on to claim this
will promote better care and, if expanded, could reduce medical costs.
Without giving government reviewers any responsibility for medical outcomes,
this approach gives them the authority to make medical judgments once the
outcomes are known. The "perfect medicine or else" approach advocated
impugns the competency and desire to provide quality care shared by the vast
majority of health-care providers and illustrates an absence of in-depth
consideration of unintended consequences.
Improved medical care at affordable cost is a proper goal, however we
believe that emphasis on patient choice and responsibility, coupled with
positive reinforcement of positive outcomes is the preferred method to
accomplish this goal. Patients should be able to select their own doctors
and, with their guidance and advice, select a course of treatment. Decisions
jointly made by patient and doctor, and payment for proper services
rendered, is the "old fashioned" doctor-patient relationship.
Under the system advocated in the NYT Editorial, the risk to the physician
of being denied payment for services could force health-care professionals
to refuse services for life saving, but difficult and dangerous procedures.
What about the specialist or super specialist who is asked to treat a
complication on a patient that is not originally his own? Since all payments
have been cut by Medicare why would he or she take such a case and face
instant personal, professional, medical-legal and financial risk?
Emergency operations on the heart, brain and aorta almost always have some
complications — many of which can be treated to save the patient's life. In
reality doctors may be forced to order more tests intended as much for risk
mitigation as for proper diagnoses. Such additional tests drive up costs
rather than decrease them and often delay care.
All medical cases are not alike. Some are relatively routine while others
are much more complex, yet current Medicare payment schedules do not
differentiate between care provided by an experienced nationally renowned
physician and that provided by a newly licensed physician. Care providers
must be treated in a fashion that encourages them to expand their training
and skills and address riskier cases without fear of financial penalties or
legal punishment.
Adjusting payment schedules based on case complexity and physician expertise
while limiting putative legal settlements would provide needed positive
incentives. The system advocated in the NYT editorial provides no such
incentives, but instead gives the authority to deny payment to anonymous
government bureaucrats many of which do not have medical expertise.
Reviewers are provided with the incentive to find as many errors, real or
imagined, as possible.
We certainly agree that some medical errors are indeed preventable and
health-care professionals and hospitals should be held responsible for
reducing such errors.
Likewise, some chronic diseases are exacerbated by risky personal behaviors
(i.e., "preventable errors" to use The NY Times term) such as drug, alcohol
and tobacco abuse, obesity and lack of exercise. Does the NY Times suggest
these patients take the medical financial responsibility for the outcomes of
their preventable behavior errors? We believe it would be preferable to
provide positive incentives, such as subsidized health care memberships, to
encourage individuals to adopt healthier lifestyles.
Although the Medicare proposal may seem appropriate at first glance, the
result will be an extremely slippery slope. This steep slope will further
destroy the patient doctor relationship, cause physicians to step away from
difficult and lifesaving procedures for fear of being punished, and force
more physicians to opt out of the Medicare system. The most serious
unintended consequence will be that more and more seniors will find
themselves without their physicians.
Editor's Note: Michael Arnold Glueck, M.D., wrote this week's commentary and
thanks Consultant Thomas Damiani who contributed to the column.
