My hospitalist medical group consists of as great collection of atheists, agnostics, and skeptics as you will ever find. But we all agree that quality is our religion. We believe to our last breath that patient care is sacred and an invaluable gift. And so, as with all faith, there is no halfway. You believe, or you stand around scratching your head asking what those other fools are worshipping. Just so with quality; there is no 50 percent attempt. You either believe that providing the best quality care is what you devoted your life to, or you are left adding up check boxes in the EMR to calculate your “quality incentive.”
Hospital administrators increasingly want to “align” their payer reimbursement to physician pay, calling it pay-for-performance, or variable compensation. Payers tie reimbursement to metrics such as readmissions, DVT prophylaxis, and many, many others through programs such as MIPS, MACRA and IPPS. “Why shouldn’t doctors be reimbursed along the same lines?” they ask.
Payers devised incentive payments because of the business case for them: Improvement on these metrics means globally better health and less cost, whether that be through private insurance or Medicare. By focusing on these population measures, we are surely improving the global health of Americans. But lost in this headlong rush towards alignment is the recognition that physicians, the best physicians at least, the ones that you want caring for you, took an ethical oath to care for their patients and that means quality is an ethical issue, not financial. Doctors harbor a secret golden spark, deep inside, which is our religion: adherence to the sanctity of the physician-patient relationship with its own inherent “quality.”
Clinicians increasingly are employed within a business structure, and are not insensitive to business concerns. Doctors respond to financial incentives, as do all humans. Capitalism works better than communism. But, the administrator’s job is to translate a clinical service into a profitable business strategy. Nothing in that job description says incentives must be “aligned.” Administration negotiates reimbursement rates with insurance companies, yet doctors are not aligned by preferentially admitting only those with the highest reimbursement. The hospital is paid more by documenting every single little patient comorbidity, thereby boosting the “case mix index”; yet doctors are not paid more for a note that includes more comorbidities. God forbid the day all our incentives are aligned! The business aspect of medicine follows many dictates that the clinical side does not; “alignment” is not a given. The best leadership creates a transparent environment that allows clinicians freedom to operate based on the best ethical concern for the patient. “Aligning incentives” is actually only code for “we have failed to create a business plan that supports a practice environment and so are asking you to do it for us.”
Clearly, American medicine is far from perfect, and even faith requires cultivation. Good medical leadership can help groups improve their quality. Medical directors should continuously review quality issues, groups can have mechanisms for internal review, and some groups even transparently publish various metrics. The mechanisms for quality improvement are as varied as the types of religious faith. But no religious faith requires payment.
Paying for faith via “indulgences” was tried by the medieval church. The result was Martin Luther’s Ninety-Five Theses and the Protestant Reformation. Well, let these be my theses posted on the All Saints’ Church door: “Do not try to pay me for quality!” I will rebel and take back my ethical practice of medicine. Join me in the Medical Reformation. Doctors, find practices that value you for your faith! Administrators, rip up those compensation plans, and hire a team that believes. The next time I myself need a doctor, the first thing I will ask is, “Are you helping me because of your Hippocratic Oath, or because of your incentive plan?” I simply won’t go see the robotic box-checkers anymore.
The Church no longer allows payment for indulgences, let’s not start doing it in medicine.
Kjell Benson is a hospitalist who blogs at The Consolation of Philosophy.
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