Reducing Overtreatment & the Profit-Motive in Healthcare

It might be easy to conclude that anyone who wants to reduce the role of the profit-motive in healthcare must be either an extremist or a fool. Upon reflection, however, it becomes clear that we are experiencing an era of overtreatment in healthcare (see, for example, Dr. H. Gilbert Welch’s piece here) and one area where it is particularly apparent is in the management of chronic pain. While there are likely many causes of overtreatment, one of them surely is the profit-motive that occurs within a fee-for-service model of reimbursement.

In the last few posts (dated 12-22-13 & 12-29-13), we have been exploring the role that the profit-motive plays in the generation of recommendations for treatment. We have seen that in a fee-for-service model of reimbursement the treatment of chronic pain can constitute a ‘perfect storm’ for overtreatment (i.e., providing an overabundance of care that has a low likelihood of effectiveness). Let’s review how it might play out.

How overtreatment occurs in chronic pain management

Patients with chronic pain are commonly distressed. This distress can lead to a willingness to try any number of medications and procedures, sometimes even repeating previously failed treatments over the years. Their healthcare providers lack any incentive to discourage such an overabundance of care, even if therapies have little chance for success. Rather, because of the fee-for-service system of reimbursement, they are in fact incentivized to make the recommendations. Indeed, the more care they recommend, the more they are likely to provide, and the more care they provide the more money they make.

It’s not that such providers are making recommendations solely on the basis of what’s in their financial best interests. As healthcare providers, they are charged to work in the best interests of the patient as well. They make recommendations and provide care in the ways they do because it is possible that such care might be helpful. If asked, they’d say that they see patients helped everyday by the medications or interventions or surgeries they provide. And it would be true.

Most any therapy can be helpful. Any clinician can point to patients for whom any numbers of the common available therapies have been helpful. For most patients and providers, this justification is good enough. If a particular therapy has been helpful in the past for Mr. Smith, why not try it for Ms. Jones? Besides, Ms. Jones has chronic pain, likely for years, and is in distress and seeking care, wanting to try something. Ms. Jones’ provider can thus recommend the therapy with a clean conscience. It’s what the patient wants and it’s possible that it will be effective.

 

Notice that the bar to justify a treatment recommendation gets set pretty low. A recommendation for a particular therapy seems reasonable if there’s a possibility of success. Both the patient and the provider seem satisfied to move forward with it, as long as it’s possible that it will be helpful. No one in this interaction seems to require a higher degree of justification, such as some degree of probability that a therapy will be effective. The possibility of effectiveness, rather than then probability of effectiveness, is good enough.

This all-too-common justification for treatment recommendations leads to overtreatment because it masks the profit-motive that underlies it. As we saw in our initial post, the justification only seems reasonable when it occurs within the context of a fee-for-service reimbursement system. In other words, providers would require a higher level of justification, if they themselves were the payer of the fee for the therapy, rather than the receiver of the fee. In a capitated system, for example, where providers stand to lose money rather than gain money when providing care, they might inquire more fully into how likely a given treatment will be effective before proceeding, rather than simply asking whether it might be effective. In contrast, in a fee-for-service system of reimbursement, there is no incentive to have a higher criterion for the care we deliver.

This state of affairs leads to scenarios like those of patients I see everyday. Working in chronic pain rehabilitation, we tend to evaluate patients after they have exhausted countless pharmacological, interventional, and surgical options – no matter how remotely likely they were to have been effective. The typical patient we see is in their forties or fifties and has had chronic pain for more than five years. They have been managed on opioids for most of these years. As a consequence, by the time they get referred to us, our patients have trialed a number of opioids and have become tolerant to even very high doses. They typically have been to two or more interventional pain clinics, where over the years they have had ten to twenty spinal injections and have had three or four repeated radiofrequency neuroablations. They commonly have had three or more spine surgeries.

I am not exaggerating.

They often tell me that I am the first person who has ever told them that they have chronic pain. I sometimes find it difficult to believe. I think what they must mean is that I was the first person to tell them in a way that they really understood – that “chronic” really means chronic, i.e., incurable. What they tell me, though, is that all other providers have tended to leave them with the impression that, while their pain has been long-lasting, it’s only a matter of finding the right procedure and they can be cured. When I ask, they tell me that no provider has ever sat them down and had a serious discussion of exactly how unlikely such a cure really is. Instead, what appears to happen is that they have undergone countless procedures and therapies over the years with very little chance of serious success. What it appears is that they have been overtreated.

Overtreatment in chronic pain management is exceptionally common. It is not just my impression. It’s been shown in systematic ways that the rates of use of opioids, interventional procedures, and spine surgeries have grown exponentially over the last few decades (Deyo, et al., 2009; Manchikanti, Pampati, et al., 2010).

What can healthcare providers do?

The first thing any provider can do is to decide whether this state of affairs is a problem or not.

I suspect that some providers in chronic pain management won’t think it is problematic at all. Spine surgeons and interventional pain providers profit greatly from the current fee-for-service practice patterns (Medical Group Management Association, 2011). Recurrent studies over the years show that their routine care for pain disorders persistently fail to follow established guidelines for common conditions, such as back pain. Instead of obtaining care that professional organizations agree is the most effective, patients continue to obtain MRI or CT scans, interventional procedures, and spine surgeries at increasingly high rates (Deyo & Mirza, 2006; Deyo, et al., 2009; Hrudey, 1991; Ivanova, et al., 2011; Mafi, et al., 2013; Pham, et al., 2009). Such less than optimal tests and procedures constitute some of the most over-utilized assessments and treatments in our healthcare system.

Thought leaders in the field of interventional pain management advocate against policy changes that encourage the use of empirically supported treatments (Manchikanti, Falco, et al., 2010). Organizations of both spine surgeons and interventional pain providers have also advocated against the Affordable Care Act and its provisions to encourage the use of empirically effective treatments (see, for example, Branch & Rao, 2009; Manchikanti, et al., 2011).

Many of us, however, in chronic pain management consider overtreatment unacceptable and are committed to delivering healthcare based on what’s most effective. Indeed, it is a moral obligation. Whether done out of a business practice or ignorance or both, it is simply wrong to withhold the most effective therapy from patients or to recommend tests and procedures that lie outside of treatment guidelines, assuming that guideline based treatments have not already been tried.

If your patient had cancer, you wouldn’t want him or her to pursue less effective treatments before pursuing more effective treatments. But, this is exactly the scenario of care that most chronic pain patients get recommended today in our field.

These points bring us to the next thing that providers can do to reduce profit-motive and overtreatment in chronic pain management.

Learn about established treatment guidelines

The American Pain Society has developed and published a number of treatment guidelines. A brief list of them can be found here.

As a profession, we are called to first provide the most effective care to our patients. To do so, we first need to know what these therapies are. We are therefore obligated to know these therapies and to provide them or refer accordingly.

Take the time to teach patients about what therapies are most effective

It takes time to teach patients why orthopedic treatments for chronic pain, such as spine surgeries and interventional procedures, are commonly ineffective. The prevailing zeitgeist remains that chronic pain is an orthopedic condition. Initially, it often doesn’t make sense to patients why rehabilitation therapies are more effective.

A common complaint among providers is that it takes too much time to explain it to patients and so often ‘the path of least resistance’ is to refer them to orthopedic care that lies outside the treatment guidelines (see, for example, this problem as discussed by DeNoon in the Harvard Health Blog).

Another version of the profit-motive, however, underlies this complaint. It only takes too much time to explain to patients important aspects of their care if you are attempting to see as many patients as possible as a means to increase productivity reimbursement.

If, however, we take our calling as a profession as the primary value, and place business as a secondary value, then the practice of taking time to explain to patients the nature of their condition and the reasons why they should pursue guideline based care becomes our moral obligation. It’s not inefficient. It is not a nuisance or an inconvenience. It’s our job.

We have the opportunity everyday – often multiple times daily – to do our job and explain to patients the following: chronic pain syndromes are a nervous system problem and not an orthopedic problem; and chronic pain syndromes are most effectively treated with chronic pain rehabilitation programs, not narcotics, spine surgeries, and interventional procedures.

To help in these discussions, refer patients and their families to the Institute for Chronic Pain and other resources. Indeed, keep a list of reputable websites and blogs to provide to patients so they can continue to educate themselves.

Support policies and organizations that encourage effective care over profitable care

Support organizations such as the following:

If you find important information, pass it on to all of those in your network. (Indeed, please pass this blog post on to all in your network.)

Also, if you are an American healthcare provider, support policies and laws, such as the Affordable Care Act (ACA), that encourage experimentation with getting away from the fee-for-service reimbursement system. For example, in some minimal ways, the ACA contains policies that experiment with moving away from paying provider organizations based solely on the quantity of patients they see and quantity of tests and procedures they perform; instead, it begins to experiment with paying provider organizations based on the quality of their performance in keeping people well. The jury remains out, of course, whether such projects will prove fruitful, but their intention is an admirable attempt to reduce the profit-motive in healthcare and subsequently reduce overtreatment.

Suggested reading: Unnecessary care: Are doctors in denial and is the profit motive to blame?

References

Branch, C. & Rao, R. (July 28, 2009). Letter to Honorable Speaker Pelosi. Retrieved from http://www.spine.org/Documents/NASSHealthCareReformLetterPelosi.pdf

DeNoon, D. (July 31, 2013). Back pain often overdiagnosed and overtreated. Harvard Health Blog. Retrieved from http://www.health.harvard.edu/blog/back-pain-often-overdiagnosed-and-overtreated-201307316546

Deyo, R. A. & Mirza, S. K. (2006). Trends and variations in the use of spine surgery. Clinical Orthopedics 433, 139-146.

Deyo, R. A., Mirza, S. K., Turner, J. A., & Martin, B. I. (2009). Overtreating back pain: Time to back off? Journal of the American Board of Family Medicine, 22(1), 62-68. doi: 10.3122/jabfm.2009.01.080102

Hrudey, W. P. (1991). Overdiagnosis and overtreatment in low back pain. Journal of Occupational Rehabilitation, 1(4), 303-312.

Ivanova, J. I., Birnbaum, H. G., Schiller, M., Kantor, E., Johnstone, B. M., & Swindle, R. (2011). Real-world practice patterns, health-care utilization, and costs in patients with low back pain: The long road to guideline-concordant care. Spine Journal, 11(7), 622-632.

Mafi, J. N., McCarthy, E. P., Davis, R. B., & Landon, B. E. (2013). Worsening trends in the management and treatment of back pain. JAMA Internal Medicine, 173(17), 1573-1581. doi: 10/1001/jamainternmed.2013.8992

Manchikanti, L., Caraway, D., Parr, A. T., Fellows, B., & Hirsch, J. A. (2011). Patient Protection and Affordable Care Act of 2010: Reforming the healthcare reform for the new decade. Pain Physician, 14, E35-E67. Want to do away with the measures that change fee-for-service to reimbursement systems that pay for effectiveness

Manchikanti, L., Falco, F., Parr, A. T., Boswell, B., & Hirsch, J. A. (2010). Facts, fallacies, and politics of comparative effectiveness research: Part I: Basic considerations. Pain Physician, 10, E23-E54.

Manchikanti, L., Pampati, V., Singh, V., Boswell, B., Smith, H. S., & Hirsch, J. A. (2010). Explosive growth of facet joint injections in the Medicare population in the United States: A comparative evaluation of 1997, 2002, and 2006 data. BMC Health Services Research, 10, 84. doi: 10.1186/1472-6963-10-84

Medical Group Management Association. (2011). Physician Compensation and Production Survey 2011 Report Based on 2010 Data. Washington DC: Medical Group Management Association.

Pham, H. H., Landon, B. E., Reschovsky, J. D., Wu, B., Schrag, D. (2009). Rapidity and modality of imaging in acute low back pain in elderly patients. Archives of Internal Medicine, 169(10), 972-981. doi: 10.1001/jamainternmed.2009.78

Author: Murray J. McAllister, PsyD

Date of last modification: 1-5-2014

How to Reduce the Influence of Money on your Healthcare

In the last post, we looked at the influence of money on your healthcare providers’ recommendations. We saw that in a fee-for-service model of healthcare, which is the predominant model in the U.S., individual providers, clinics and hospitals get paid based on the number of patients they see and the number of procedures and tests they perform. In other words, the more patients a provider, clinic, or hospital sees or the more procedures or tests they perform, the more they get paid. As such, a fee-for-service model of healthcare incentivizes productivity – providing more care leads to making more money.

In turn, the financial incentives of the fee-for-service model can lead to overtreatment. Overtreatment is care that is provided despite a high likelihood that it will be ineffective or unnecessary.

Chronic pain patients are especially prone to overtreatment. Chronic pain can be a highly distressing experience. It can be difficult to accept. As such, patients and their providers can go against all odds to get rid of it. It’s not uncommon to see patients who have had numerous interventions and surgeries, often with the same procedures repeated even when they weren’t initially helpful.

The fee-for-service model of reimbursement reinforces the pattern of pursuing care that has little chance of success. Providers financially benefit from providing care whether or not there is much chance that it will significantly reduce pain or improve function.

This combination of factors – difficulties in accepting the chronicity of pain and the fee-for-service model of reimbursement – is a ‘perfect storm’ for overtreatment in chronic pain. It leads to providers making recommendations based on the possibility of effectiveness rather than the probability of effectiveness. It’s a certain willingness on the part of patients and their providers to try something to reduce pain, even if it is not very likely to be helpful.

Over the past twenty years, the field of chronic pain management has witnessed exponential growth of the use of spine surgeries, interventional procedures (i.e., epidural steroid injections, nerve blocks, neuroablations, and the like), and opioid medications. The growth rates of this care have occurred despite evidence that they are not particularly effective. During this period of time, there have been record numbers of disability applications for chronic pain (Deyo, Mirza, Turner, & Martin, 2009) and numerous publications of clinical trials, reviews, and meta-analyses that show that these treatments are unlikely to be helpful for most patients (see, for example, Gibson & Waddell, 2007; Martell, et al., 2007; van Tulder, et al., 2006; van Wijk, et al., 2005).

Why, then, do healthcare providers continue to recommend them at such high rates? Patients, of course, might be excused for not knowing that these common therapies are ineffective for most people, but healthcare providers should know about their low level of effectiveness. While they might know of the research, it may be that it doesn’t enter into their decision-making process when making recommendations on a day-to-day basis. Here’s how it might play out.

All these therapies can help some minority of people. That is to say, it’s possible that they are helpful for any given patient. However, it’s not likely that they will be helpful. This distinction can get overlooked in a fee-for-service reimbursement system. Money comes to influence healthcare recommendations because providers, clinics, and hospitals get paid based on quantity of patients seen and procedures provided, not on how healthy patients become or how effective procedures are.

In a fee-for-service reimbursement system, the criteria for whether to pursue a treatment gets lowered to whether it is possible that the procedure could be helpful, and not whether it is likely that it will be helpful. The consequence is overtreatment.

So, what can you, the patient, do about it?

Importance of the therapeutic relationship

As a patient, you can do a number of things to reduce the role that money might play in your care. They all relate to being able to establish and maintain a healthy therapeutic relationship with your chronic pain management provider(s) that allows you to make effective and informed decisions about your care.

What does such a healthy therapeutic relationship look like? It’s a safe, non-judgmental relationship in which you can have mature, adult-to-adult discussions about your concerns and your care. It’s a relationship in which you can take an active role in the decision-making processes of your care. I sometimes tell patients to think of it like a high school or college level seminar in which the things that you are discussing are open to interpretation and respectful debate. There is no absolute, right-or-wrong way of going about managing chronic pain. There is no clearly defined conventional agreement about what treatments to pursue and what not to pursue, even for common conditions, such as chronic low back pain. As such, recommendations for treatment are open to some respectful debate. If you have a safe, non-judgmental relationship with your healthcare provider, you can have an adult-to-adult, respectful debate about what to do.

Appreciate the conflict of interest that your healthcare provider has

In this relationship, you can keep in the back of your mind an appreciation for the inherent tension that occurs in your healthcare provider when practicing in a for-profit healthcare system. On the one hand, as a professional and based on a high level of expertise, your healthcare provider is charged to act in your best interest, making recommendations that are going to work best for you. On the other hand, understand that your healthcare provider is also operating a practice that is essentially a business, one in which your healthcare provider’s recommendations also serve his or her own self-interest. When you appreciate this inherent tension in the relationship that you have with your healthcare provider, you are in a better position to make more informed decisions.

The point, here, is not to accuse providers within a for-profit healthcare system of wrong-doing. They are simply engaging in the practice of healthcare delivery in the manner that is encouraged by their system. Rather, the point, here, is simply to know the lay of the land, as it were. The ground on which you stand when obtaining care from a chronic pain management provider involves an inherent tension between conflicting motivations. The provider, clinic, or hospital that you seek care from is attempting to work in your best interest and their own self-interest at the same time. It’s important that you understand this tension that is inherent in the recommendations that you receive from your chronic pain management providers and take it into account as you decide on which recommendations to pursue and which not to pursue.

Stay grounded when making decisions about your care

It also helps if you can stay grounded when making decisions about your healthcare. While it is understandable that you may become overwhelmed or desperate or angry at times, you likely may not make your best decisions when feeling these ways. It fosters the likelihood that you’ll be willing to ‘take a long shot’ – a treatment that might work, but is unlikely to work. In turn, being willing to try anything, fosters unnecessary care, which may be recommended to you in part because of profit motive. Instead, you will be more successful in managing pain when you make decisions about treatment based on probability of effectiveness, not the possibility of effectiveness. While all things are possibly helpful, only a few things are likely to be helpful. So, when you are ungrounded and apt to want to ‘throw a Hail Mary pass,’ maybe the first thing to do is to get grounded and then have a respectful, adult-to-adult discussion with your healthcare provider about what treatment is most likely to be helpful.

Know which treatments are effective and which are not effective

Related to this point, and in order to have such a grounded discussion that minimizes the role of money in your healthcare, you need to know what is effective and what is not effective in the management of chronic pain. The Institute for Chronic Pain and other organizations (such as Body in Mind) attempt to translate published, clinical research into language that is approachable to patients, their families, primary care providers, and third-party payers. To minimize the role that money plays in your care, it pays to educate yourself about the empirical evidence for the effectiveness of common treatments for chronic pain. By having a command of such knowledge, you will be able to have a more sophisticated discussion with your healthcare providers about the recommendations that you receive.

Seek out second opinions

Another important strategy is to seek out second opinions from providers whose training and practice are different from the provider who made the initial recommendation. By doing so, you allow yourself a greater amount of options from which you can make a more informed decision about your care. As such, it minimizes the risk of acting on recommendations that may in part have been provided based on profit motive.

For example, if you receive a recommendation from a spine surgeon for your chronic low back pain, don’t just seek out a second opinion from another surgeon, who may very likely come up with the same recommendation; rather, seek out a second opinion, say, from a chronic pain rehabilitation provider who will likely conceptualize and treat your chronic low back pain differently.

Understand that there is no conventional agreement as to how to manage common chronic pain disorders. Surgeons, interventional pain providers, and chronic pain rehabilitation providers all treat the same condition differently. Among all the different types of chronic pain management providers, there is considerable debate as to how to conceptualize and treat chronic pain. Some commonly performed procedures have very little empirical support for their effectiveness and still others have been shown to be ineffective. In the on-going debate, it is common to highlight the potential role of the profit motive when discussing why these procedures continue to be performed (see, for instance, Deyo, Nachemson, & Mirza, 2004; Perret & Rosen, 2011; Weiner & Levi, 2004).

When you obtain a second opinion that is outside the field of the initial recommendation, you are more apt to obtain an opinion that reflects another side of the debate that goes on among chronic pain management providers. In doing so, you learn about options that you might not otherwise obtain. Subsequently, you can learn about the relative effectiveness of each option you receive, discuss them with your healthcare providers, and foster an informed decision. Consequently, you minimize the degree to which profit motive influences the recommendations you receive and pursue.

Seek out care from salaried providers or non-profit organizations

Lastly, if you have the option, seek out healthcare providers who work in organizations that pay them on a salary, rather than through a fee-for-service model. When the livelihood of your healthcare providers are not dependent on whether you give consent to the recommendations they provide, you minimize the role that money plays in generating those recommendations. It’s interesting to note that some of the most prestigious healthcare institutions in the U. S. pay their healthcare providers on a salary. Some examples are the Mayo Clinic, the Cleveland Clinic, the VA, Kaiser Permanente, and GroupHealth.

Of course, many patients do not have the option to seek care in one of these organizations. In such circumstances, you might try to obtain care in a non-profit healthcare organization. Non-profit organizations might still pay their providers through a fee-for-service system, but they may also have a mission that tempers the profit motive of their individual providers.

References

Deyo, R. A., Mirza, S. K., Turner, J. A., & Martin, B. I. (2009). Overtreating back pain: Time to back off? Journal of the American Board of Family Medicine, 22(1), 62-68. doi: 10.3122/jabfm.2009.01.080102

Deyo, R. A., Nachemson, N., & Mirza, S. K. (2004). Spinal-fusion surgery: The case for restraint. New England Journal of Medicine, 350, 722-726.

Gibson J. N., & Waddell, G. (Updated January 6, 2007). Surgical intervention for lumbar disc prolapse. In Cochrane Database of Systematic Reviews, 2007 (2). Retrieved December 27, 2013, from The Cochrane Library, Wiley Interscience.

Martell, B. A., O’Conner, P. G., Kerns, R. D., Becker, W. C., Morales, K. H., Kosten, T. R., & Fiellin, D. A. (2007). Systematic review: Opioid treatment for chronic back pain: Prevalence, efficacy, and association with addiction. Annals of Internal Medicine, 146, 116-127.

Perret, D. & Rosen, C. (2011). A physician-driven solution – The Association for Medical Ethics, the Physician Payment Sunshine Act, and ethical challenges in pain management. Pain Medicine, 12, 1361-1375.

van Tulder, M. W., Koes, B., Seitsalo, S., & Malmivaara, A. (2006). Outcomes of invasive treatment strategies in low back pain and sciatica: An evidence based review. European Spine Journal, 15, S82-S89.

van Wijk, R. M., Geurts, J. W., Wynne, H. J., Hammink, E., Buskens, E., Lousberg, R., Knape, J. T., & Groen, G. J. (2005). Radiofrequency denervation of lumbar facet joints in the treatment of chronic low back pain: A randomized, double-blind, sham lesion-controlled trial. Clinical Journal of Pain, 21, 335-344.

Weiner, B, K. & Levi, B. H. (2004). The profit motive and surgery. Spine, 29, 2588-2591.

Author: Murray J. McAllister, PsyD

Date of last modification: 2-29-2014

How Money Influences Healthcare Recommendations

One of the more common sentiments that patients express to me is that they have come to the conclusion that money influences healthcare recommendations. After reflecting on all the years of chronic pain and all the years of failed treatments, many of which were tried multiple times, they have concluded that the business side of healthcare played too much of a role in their own care. They are now disappointed, angry, and jaded about how much they trust healthcare providers.

Sometimes, the sentiment comes when they first accept that their chronic pain is really chronic. They wonder why no one ever sat them down and talked with them about how their pain is actually chronic. What they got instead, they say, were healthcare providers who kept recommending procedure after procedure that were all vain attempts to cure something that they should have acknowledged was a chronic condition. It must have been for the money, they conclude.

Sometimes, the sentiment comes after patients learn how ineffective common surgical and interventional procedures are. They subsequently wonder why, if it’s not for the money, healthcare providers recommend treatments that well-designed studies have shown to be ineffective.

Sometimes, too, they come to wonder about the role of money once they have participated in a chronic pain rehabilitation program. After being on opioid medications for many years, they go through a program and come to learn how to self-manage pain without the medications. Once they get over their initial shock that they really can manage pain without opioids, they begin to wonder, “Why didn’t anyone ever refer me to a program like this before?” Then, they start wondering about the role that money might have played in continuing them on opioids for many years without ever referring them to a program that could have shown them how to live well without the medications.

However the sentiment arises, patients with chronic pain express it fairly often: money influences healthcare recommendations.

So, is it true that money can play a role in the recommendations that healthcare providers make? I think that most healthcare providers would quietly acknowledge that it is true. A number of commentators in the field also acknowledge it (see, e.g., Deyo, Nachemson, & Mirza, 2004; Perret & Rosen, 2011; Weiner & Levi, 2004).

Like most things in life, though, it’s complicated. The question doesn’t lend itself very well to a simple ‘yes or no’ response. Let’s look at some of these complications so that we can appreciate how complicated the issue really is. It’s important to have an accurate understanding and appreciation for the issue, because, after all, it’s not true that all healthcare is bad even if things like the profit-motive sneak into it and influences it. We need healthcare. It’s too simple and likely not good for any of us to get so mad at its imperfections that we become jaded and forego it. We shouldn’t throw the baby out with the bath water, as the old saying goes. Rather, we can acknowledge its imperfections and take them into account in order to make clear-headed decisions about the recommendations that our healthcare providers make. By having a sophisticated understanding and appreciation for how healthcare works, we can make better and more informed decisions about the recommendations that we receive – whether to pursue them or not.

The following is the first of a three-part series on the role of the profit-motive in healthcare, particularly as it relates to the management of chronic pain. This first blog post focuses on how money influences healthcare recommendations. The two following posts will be about 1) what you, as a patient, can do about it, and 2) what healthcare providers can do about it.

Fee-for-service reimbursement influences healthcare recommendations

In countries where healthcare delivery is a for-profit industry, financial incentives can influence recommendations. To see how, we need to provide a quick review of how financial reimbursement works in a for-profit health care industry.

In the U. S., for example, most hospitals, clinics, and individual providers get paid a set amount of money every time they see a patient or perform a procedure or order a test. This system of reimbursement is called ‘fee-for-service.’ Individual providers are commonly akin to independent contractors with their practice being their business and their livelihood dependent on how many patients they see and how many procedures and tests they provide. In addition, administrators of hospitals and clinics track and evaluate providers’ performance based on ‘productivity’ (i.e., how many patients that are seen and how many procedures and tests that are provided).

Notice the subtle value system at work. Healthcare providers make more money when they see more patients and perform more procedures and tests. Their administrators will subsequently see those providers with the highest productivity as most favorable. Administrators promote or lay off healthcare providers in part based on productivity or lack of it. In all these ways, fee-for-service reimbursement creates incentives to provide more rather than less care.

Now, we all know that incentives influence behavior. It’s true in all walks of life and it is similarly true in for-profit healthcare. Fee-for-service incentives influence the type and amount of recommendations that patients receive from their providers, clinics and hospitals. It stands to reason that such influence occurs. Sales people are rarely salaried employees. Rather, they are paid on commission because it influences them to be more productive in the amount of sales they produce – the more they sell, the more they are paid and the more their positions remain safe from being laid off. It’s the same with most healthcare providers – the more patients they see and the more procedures and tests they recommend and convince patients to have, the more they get paid and the more their administrators value their position.

There are actual studies that demonstrate the influence of incentives on productivity in healthcare. For example, Hickson, Altmeier, and Perrin (1987) compared salaried physicians to fee-for-service physicians. Both groups involved the same type of physician and saw the same types of patients. The fee-for-service physicians saw more patients than the salaried physicians.

Likewise, Strope, et al. (2009) studied a recent trend for providers to build their own ambulatory surgery centers and subsequently change the site where they perform procedures, from the hospital or clinic, to the ambulatory surgery center that they own. The advantage of performing procedures at an ambulatory care center that the provider owns is that the provider will make more money. Specifically, they get to bill at a higher rate than in the clinic, even if it is for the same procedure, and they get to keep the money that ordinarily would have gone to the hospital for the use of the hospital facilities. So, what did Strope, et al., find in their study of this recent trend? Once providers could bill at higher rates of reimbursement and subsequently collect more money, the rate of procedures significantly increased, including the most profitable procedures. It’s hard to argue, in such circumstances, that need for such procedures dramatically changed once providers came to own the surgery centers.

Similarly, providers who own their own imaging devices (e.g., X-ray, CT or MRI scans) are upwards of eight times more likely to order scans than those who don’t own their own imaging devices, even when the latter providers are from the same specialty and are seeing the same type of patients with the same types of health problems (Kouri, Parsons, and Alpert, 2002). Again, it’s hard to argue that those providers who own their own imaging devices have somehow tapped into an unmet need of patients (see, for example, Fisher & Welch, 1999).

Rather, it stands to reason that such incentives lead to healthcare providers seeing more patients and providing more recommendations to undergo procedures and tests. As such, incentives to make more money can influence what and what doesn’t get recommended.

The concern is that money influences healthcare recommendations in such a way that it leads to unnecessary and/or ineffective care. As seen above, healthcare providers who own their own facilities or equipment have dramatically higher rates of procedures and tests than the same type of healthcare providers who don’t own their own facilities or equipment. Are the dramatically higher numbers of procedures and tests necessary? If they are unnecessary, they likely do not add value to the diagnosis or treatment of the condition of the particular patient. In other words, under these circumstances, they are ineffective for the particular need of the patient.

The pressure of a fee-for-service system of healthcare can similarly lead to unnecessary and therefore ineffective treatments and tests in the management of chronic pain. It’s common to see patients who have a history of obtaining multiple series of the same surgical or interventional procedures at different clinics, even though the first series turned out to be ineffective for their particular pain condition. Why did the subsequent providers think that repeating the same series of interventional procedures or re-doing the spine surgery was a good idea when previously the procedures were ineffective?

How money influences clinical decision-making

To be fair, there are likely many factors at work that go into a decision to make a recommendation for a particular treatment and not just the fact that the provider will personally profit from delivering the treatment.

Imagine, for example, that you are the provider in the following scenario. You have a patient who has chronic pain and is in some degree of distress about it. You’ve learned that the patient has already had a series of interventional procedures, say, and they were not helpful in reducing pain. However, you are an interventional pain provider and interventional procedures are what you do. The patient is there, at your clinic, and wants you to do something. Might you not reason to yourself, ‘well, there’s a chance that it might work, even if it’s unlikely to work, and the patient wants me to try something; rather than sending the patient away without doing anything and making him or her dissatisfied, let’s give it a try.’ We could call this type of clinical decision-making the ‘we might as well give it a try’ decision.

At first blush, it doesn’t seem like the fact that you will personally profit from the procedure has anything to do with the decision. Indeed, the decision seems to be able to stand on its own, as it were. The patient is in pain and is upset about it. The patient wants you to do something. It just so happens that what you do is something that has already been tried and failed in the past. However, there’s still a chance that it might now work. If it works, the patient will be happy. If it doesn’t work, you can say that at least you tried. If you don’t do anything and send the patient away, they’ll likely be more upset than they are now. So, you ‘might as well give it a try.’ The argument seems to stand on its own without needing to reference the fact that you will personally profit from the procedure. This last statement might be true at least until we change the scenario a little by changing the reimbursement system.

Suppose, for instance, that, rather than a fee-for-service system where you profit directly from delivering the care, you work within a capitated system of reimbursement where the profit lies in providing the least and most effective care possible. In a capitated system, providers are not given a fee each time they see a patient or perform a procedure. Instead, they are given a set amount of money for the entire care of a patient for a certain time frame, such as a year. The set amount of money will cover all the care that the patient needs for the given time frame. The incentive in a capitated system is to keep people healthy and out of the doctor’s office so that they don’t use up the set amount of money with frequent visits, procedures, and tests. It also incentivizes providing the care that’s most likely to be effective, and minimizing any ineffective or unnecessary care – again, for the same reason, so that the patients don’t use up the set amount of money that was previously given for their care over the year. Capitated systems of reimbursement are not very common these days, though they were the heart of the HMO system back in the 1970-80’s in America.

Nonetheless, suppose that, as the interventional provider in our scenario, you are now working under such a system of reimbursement. Under this system, would you be as inclined to come to the same decision to repeat a series of interventions that had previously failed– the ‘we might as well give it a try’ decision. Providing the interventional procedures are going to hurt, rather than help, your bottom line. You are still charged to care for the patient who is in pain and distress, but would you use up the set amount of money that you were given by performing procedures that have already been done and were ineffective? Might it not be the case that you would reason against it now? In this scenario, the fact that the series of interventions has already been tried and failed seems to take on greater importance. You would weigh the previously failed treatment more heavily in your decision-making process. In your clinical decision-making process, you might reason, ‘well, why repeat a failed treatment?’

At first blush, it seems like a perfectly reasonable decision. If your car wouldn’t start and you had already paid one mechanic to fix it and the repair didn’t work, you wouldn’t take it to another mechanic and pay for the exact same repair. Rather, you’d want to pursue a different approach. Similarly, as the interventional provider, your decision to refrain from pursuing the same procedure that previously had not worked seems sound.

But, let’s step back for a second, and take stock of our two different, albeit reasonable, decisions.

It’s the same patient with the same condition, but you’ve come to two contradictory treatment recommendations. The only difference that accounts for the different treatment recommendations is how you will get reimbursed. Notice how subtly money influences your decision-making.

It’s an uncomfortable fact that the system of reimbursement in healthcare can influence clinical decision-making.

In the posts to follow, we’ll review what you, the patient, can do to minimize the role that money has in the recommendations that you receive and decide to pursue. Then, we’ll review what us healthcare providers can do to reduce the role that money has on our recommendations.

References

Deyo, R. A., Nachemson, N., & Mirza, S. K. (2004). Spinal-fusion surgery: The case for restraint. New England Journal of Medicine, 350, 722-726.

Fisher, E. S. & Welch, H. G. (1999). Avoiding the unintended consequences of growth in medical care: How might more be worse? Journal of the American Medical Association, 281(5), 446-453.

Hickson, G. B., Altmeier, W. A., & Perrin, J. M. (1987) Physicians reimbursement by salary or fee-for-service: Effect on physician practice behavior in a randomized prospective study. Pediatrics, 80(3), 344-350.

Kouri, B. E., Parsons, R. G, & Alpert, H. R. (2002). Physician self-referral for diagnostic imaging: Review of the empiric literature. American Journal of Roentgenology, 179(4), 843-850.

Perret, D. & Rosen, C. (2011). A physician driven solution – The association for medical ethics, the physician payment sunshine act, and ethical challenges in pain management. Pain Medicine, 12, 1361-1375.

Strope, S. A., Daignault, S., Hollingsworth, J. M., Ze. Z., Wei, J. T., & Hollenbeck, B. T. (2009) Physician ownership of ambulatory surgery centers and practice patterns for urological surgery: Evidence from the state of Florida. Medical Care, 47(4), 403-410.

Weiner, B, K. & Levi, B. H. (2004). The profit motive and surgery. Spine, 29, 2588-2591.

Author: Murray J. McAllister, PsyD

Date of Last Modification: 12-22-2013