December 15, 2005, 8:19 a.m.
Do No Harm
A new health-care proposal violates the first rule of medical practice.

By Richard Dolinar & S. Luke Leininger

Nearly everyone knows the first rule doctors are taught when learning to treat patients: "Do no harm." As a nation and as doctors, we should also apply this rule to health-care policy. Unfortunately, we don't.

The Senate Finance Committee recently reported out major budget legislation that would implement a "pay-for-performance" system for doctors and other medical professionals who treat Medicare patients. The Senate legislation would tie physician compensation to their level of compliance with government-dictated treatment directives. Sounds harmless enough. Why should the government pay doctors for a lack of performance?

But there's a problem. Not only is there little evidence that the government's version of a "pay-for-performance " scheme would actually work to the benefit of patients, but there is also the likelihood it would do the opposite.

Understand that "pay for performance" in Medicare would mean that Congress would pay doctors according to how well they've complied with government-defined medical guidelines. That would create another layer of bureaucracy between patients and doctors, and it would involve federal bureaucrats even more in patient care.

Some members of Congress seem to think this latest scheme will help them control rapidly rising Medicare costs while improving patient care. Of course, lawmakers must know that the current Medicare payment system they created is deeply flawed, and it fails to reward doctors for the quality and benefits of their services to Medicare patients.

That system consists of rigid price controls and central planning. It has failed to reward quality of care, even as Medicare costs are soaring. If Congress wants to improve patient care in a cost-effective fashion, another layer of bureaucracy and red tape isn't the way to go.

Consider the recent work of health-policy researcher Meredith Rosenthal, who published information on "pay for performance" in The Journal of the American Medical Association. Her article was accompanied by an editorial noting that in healthcare there have been "only nine randomized controlled trials of pay for performance ... reported in the literature." A closer look at those trials reveals that there's little unequivocal data to support this approach and, as the editorial goes on to state, "Even these studies are not clearly applicable to current pay for performance."

Isn't it ironic that with a growing professional and political interest in "evidence-based medicine," some members of Congress are practically racing to enact a Medicare "pay-for-performance" system, which has no evidence to support it and plenty of evidence that discredits it?

Clearly, factors other than the presence or absence of financial bonuses influence the care patients receive. In fact, offering to pay doctors financial bonuses is usually superfluous. They already have plenty of other reasons to treat patients well.

These include the desire to help another human being who is suffering, pride in one's work, use of one's skills to meet the challenge of the individual unique medical case and the desire to maintain a sterling reputation in one's community. And if these are not strong enough motivators, let's not forget the medical malpractice attorneys looking over doctors' shoulders as they treat patients.

Lawmakers should focus on what works and not divert the focus of doctors from exercising their best professional judgment in appropriate patient-centered medical care. The superficial financial rewards of Medicare "pay for performance" would likely create incentives to rig the system in several ways that may cause the quality of healthcare to decline, even if a handful of indicators seem to be improving.

If Congress really wants to improve patient care, it should reform Medicare itself. It could do so by creating a consumer- and information-driven system, not unlike the Federal Employees Health Benefits Program (FEHBP), which covers federal workers and retirees. Federal health plans are competitive, and participating medical professionals provide quality care at a reasonable cost, within an atmosphere of minimal government bureaucracy and light regulation. Patients have wide choices. As doctors know, when a patient takes a hand in his own care, he does better.

If lawmakers aren't willing to go that far, they should at least abolish current Medicare fee schedules and update payment formulas, allow doctors to charge either more or less than the Medicare fixed price for medical services, and require physicians to disclose the prices they charge for Medicare services.

Everyone wants to provide the best possible medical care at the best possible price. The way to do that is by allowing the market to work its magic, not by luring doctors into a bureaucratic obedience school.

When Medicare was enacted in 1965, Congress passed a law that federal officials were not to "exercise any supervision or control over the practice of medicine, or the manner in which medical services are provided." Seniors and other citizens ought not to allow Congress to repeal the letter or the spirit of that law through a back-door bureaucratic scheme.

— Richard Dolinar, M.D., is a senior fellow in health care policy at the Heartland Institute. S. Luke Leininger is a former health-policy fellow in the Center for Health Policy Studies at The Heritage Foundation.

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