Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

How pay for performance leads to overdiagnosis and overtreatment

Peter Ubel, MD
Conditions
October 8, 2014
Share
Tweet
Share

Not long ago, the Joint Commission established that patients with pneumonia should receive antibiotics within four hours of diagnosis. Timely diagnosis and treatment can be the difference between life and death in patients with this illness. In fact, some people believe this kind of quality measure should play a large role in how we pay for medical care. After all, doctors should not be paid solely on the basis of how much care they provide, but also based on the quality of that care. All else equal, a physician who treats pneumonia efficiently should be rewarded more handsomely than one who takes a fortnight to make a diagnosis.

Only one problem with this seemingly sensible view. Experts believe this four-hours-to-treat requirement leads to an overdiagnosis of pneumonia and, consequently, to an overuse of antibiotics. How we measure health care quality, and how we factor such measures into physician reimbursement, can have surprising effects on how physicians diagnose and treat patients.

Consider another life-threatening illness: sepsis, a syndrome of widespread inflammation and, at its most extreme, multi-organ failure caused by infection. Sepsis typically requires not only high power antibiotics but also intensive care from multiple specialists. A recent article in the New England Journal of Medicine suggests we may be experiencing an overdiagnosis of this syndrome, because hospitals often receive higher reimbursement for patients with sepsis than for ones with milder infections. In other words, it pays not to miss sepsis diagnoses.

As the New England Journal article points out, the rate of sepsis has been climbing in recent years, even though the infections most-likely to lead to sepsis have been stable or declining in numbers:

Sepsis-640

The moral of this story is not simple.  In fact, I raise this topic primarily as a caution to those who think better quality measurement is the key to improving health care performance. First, this story confirms that medical diagnoses aren’t purely objective, scientific exercises. Instead, they often rely upon judgment calls. There’s no absolute threshold where physicians can determine that a given infection is severe enough, inflammatory enough, to qualify as sepsis.

Second, the rise of sepsis diagnoses reveals how health care payment can influence medical judgments. We have known this for while in the U.S. We knew long ago that fee-for-service payment incentivizes health care providers to overdiagnose and overtreat patients. And we learned, when Medicare introduced lump payment systems in the 1980s — paying hospitals a fixed fee based on patients’ diagnoses — that hospitals would choose among possible diagnoses to find ones that maximized their income.

Now we know that quality measures, linked to patient diagnoses, could create similar problems. The judgments clinicians make, about what diagnoses patients have, are not independent of the way they’re paid for care. Diagnoses are not always hard and fast, but are often vague and mushy. These mushy diagnoses do not exist only because of burdensome government regulations or greedy health care providers. They exist because medical care is a sloppy enterprise. Diagnoses are not always kind enough to present themselves unambiguously. Streptococcal bacteria do not always announce when they have transformed from being harmless to pathologic to sepsis-provoking.

Because of the inherent subjectivity of medical diagnoses, those groups that assess health care quality need to remain on the alert for the unintended consequences of their measures.  And those insurers and regulators eager to establish clinical care mandates? They need to slow down and make sure their administrative fixes do not create undue side effects.

Peter Ubel is a physician and behavioral scientist who blogs at his self-titled site, Peter Ubel and can be reached on Twitter @PeterUbel.  He is the author of Critical Decisions: How You and Your Doctor Can Make the Right Medical Choices Together. This article originally appeared in Forbes.

Prev

Nursing homes: Our society has chosen to see only darkness

October 8, 2014 Kevin 1
…
Next

The problem with primary care residency programs

October 8, 2014 Kevin 4
…

Tagged as: Hospital-Based Medicine, Infectious Disease

Post navigation

< Previous Post
Nursing homes: Our society has chosen to see only darkness
Next Post >
The problem with primary care residency programs

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

More by Peter Ubel, MD

  • Clinicians shouldn’t be punished for taking care of needy populations

    Peter Ubel, MD
  • Patients alone cannot combat high health care prices

    Peter Ubel, MD
  • Is the FDA too slow to handle the pandemic?

    Peter Ubel, MD

More in Conditions

  • She wouldn’t move in the womb—then came the rare diagnosis that changed everything

    Amber Robertson
  • Diabetes and Alzheimer’s: What your blood sugar might be doing to your brain

    Marc Arginteanu, MD
  • How motherhood reshaped my identity as a scientist and teacher

    Kathleen Muldoon, PhD
  • Jumpstarting African health care with the beats of innovation

    Princess Benson
  • Voices from the inside: 35 years as a nurse in health care

    Virginia DeFranco, RN
  • Does silence as a faculty retention strategy in academic medicine and health sciences work?

    Sylk Sotto, EdD, MPS, MBA
  • Most Popular

  • Past Week

    • The broken health care system doesn’t have to break you

      Jessie Mahoney, MD | Physician
    • How dismantling DEI endangers the future of medical care

      Shashank Madhu and Christian Tallo | Education
    • How scales of justice saved a doctor-patient relationship

      Neil Baum, MD | Physician
    • “Think twice, heal once”: Why medical decision-making needs a second opinion from your slower brain (and AI)

      Harvey Castro, MD, MBA | Tech
    • The hidden cost of delaying back surgery

      Gbolahan Okubadejo, MD | Conditions
    • She wouldn’t move in the womb—then came the rare diagnosis that changed everything

      Amber Robertson | Conditions
  • Past 6 Months

    • What’s driving medical students away from primary care?

      ​​Vineeth Amba, MPH, Archita Goyal, and Wayne Altman, MD | Education
    • Internal Medicine 2025: inspiration at the annual meeting

      American College of Physicians | Physician
    • Residency as rehearsal: the new pediatric hospitalist fellowship requirement scam

      Anonymous | Physician
    • A faster path to becoming a doctor is possible—here’s how

      Ankit Jain | Education
    • The hidden bias in how we treat chronic pain

      Richard A. Lawhern, PhD | Meds
    • Are quotas a solution to physician shortages?

      Jacob Murphy | Education
  • Recent Posts

    • She wouldn’t move in the womb—then came the rare diagnosis that changed everything

      Amber Robertson | Conditions
    • Rethinking medical education for a technology-driven era in health care [PODCAST]

      The Podcast by KevinMD | Podcast
    • From basketball to bedside: Finding connection through March Madness

      Caitlin J. McCarthy, MD | Physician
    • In medicine and law, professions that society relies upon for accuracy

      Muhamad Aly Rifai, MD | Tech
    • Diabetes and Alzheimer’s: What your blood sugar might be doing to your brain

      Marc Arginteanu, MD | Conditions
    • How motherhood reshaped my identity as a scientist and teacher

      Kathleen Muldoon, PhD | Conditions

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 11 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

  • Most Popular

  • Past Week

    • The broken health care system doesn’t have to break you

      Jessie Mahoney, MD | Physician
    • How dismantling DEI endangers the future of medical care

      Shashank Madhu and Christian Tallo | Education
    • How scales of justice saved a doctor-patient relationship

      Neil Baum, MD | Physician
    • “Think twice, heal once”: Why medical decision-making needs a second opinion from your slower brain (and AI)

      Harvey Castro, MD, MBA | Tech
    • The hidden cost of delaying back surgery

      Gbolahan Okubadejo, MD | Conditions
    • She wouldn’t move in the womb—then came the rare diagnosis that changed everything

      Amber Robertson | Conditions
  • Past 6 Months

    • What’s driving medical students away from primary care?

      ​​Vineeth Amba, MPH, Archita Goyal, and Wayne Altman, MD | Education
    • Internal Medicine 2025: inspiration at the annual meeting

      American College of Physicians | Physician
    • Residency as rehearsal: the new pediatric hospitalist fellowship requirement scam

      Anonymous | Physician
    • A faster path to becoming a doctor is possible—here’s how

      Ankit Jain | Education
    • The hidden bias in how we treat chronic pain

      Richard A. Lawhern, PhD | Meds
    • Are quotas a solution to physician shortages?

      Jacob Murphy | Education
  • Recent Posts

    • She wouldn’t move in the womb—then came the rare diagnosis that changed everything

      Amber Robertson | Conditions
    • Rethinking medical education for a technology-driven era in health care [PODCAST]

      The Podcast by KevinMD | Podcast
    • From basketball to bedside: Finding connection through March Madness

      Caitlin J. McCarthy, MD | Physician
    • In medicine and law, professions that society relies upon for accuracy

      Muhamad Aly Rifai, MD | Tech
    • Diabetes and Alzheimer’s: What your blood sugar might be doing to your brain

      Marc Arginteanu, MD | Conditions
    • How motherhood reshaped my identity as a scientist and teacher

      Kathleen Muldoon, PhD | Conditions

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

How pay for performance leads to overdiagnosis and overtreatment
11 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...