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 healthcare 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 Times editorial, the risk to the physician of being denied payment for services could force healthcare 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 Times 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 healthcare 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 Times term) such as drug, alcohol, and tobacco abuse, obesity and lack of exercise. Does the 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 healthcare 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.
Michael Arnold Glueck, M.D., comments on medical-legal issues and is a visiting fellow in economics and citizenship at the International Trade Education Foundation of the Washington International Trade Council.
Robert J. Cihak, M.D., is a senior fellow and board member of the Discovery Institute and a past president of the Association of American Physicians and Surgeons.
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