Well, over the past few weeks and months I’ve been thinking about what the major influences are on health care practice. Is it ‘the evidence’? Is it patient need? Is it patient demand? Is it treatment provider preference? hmmmm, actually it is most likely to be whoever pays for the service, especially in New Zealand, where there are two major purchasers – the Ministry of Health, and Accident Compensation Corporation (For those who are not familiar with this system, head here for more details).
I’ve always been keen on ensuring that treatments actually help people in the real world, and don’t simply reduce distress in the short term – which means I’ve supported ensuring that services provided have a specific focus, that goals are identified, that treatment is based on a solid assessment foundation, and that there are regular reviews to ensure treatment has an end point.
I’ve also been a strong advocate of ensuring that health professionals should be comfortable with delivering a transparent service – ensuring the person being treated is aware of not only treatment options, but also the implications of choices, and the content of reports to case managers, referrers, GP’s and others.
I think this is about honesty, integrity and minimising the ‘mystery’ about pain management that can sometimes lead to ‘turf protection’ by health professionals, and disreputable providers providing inappropriate services.
I don’t even mind that purchasers can indicate what they would like the services they buy to do – after all, they need to know what they’re getting for their money, and both the purchaser and ourselves, both want to make sure the person receiving treatment returns to optimal health.
There are certain points, however, where it’s important that the professional expertise of a clinician needs to be respected. There is a reason that health professionals spend time continuing to develop skill and expertise – and that’s so we are able to deliver interventions that are effective.
Let me give you a parallel. If I have a dent in my car, I take it to a panelbeater. I ask the panelbeater to work out what’s wrong and then give me a call to let me know what’s wrong and how much it will cost to fix it. I then decide whether I want to proceed with the repair. If I think the price is too high, I may phone around to see what other panelbeaters charge, making sure I know what’s included in their fee. I then decide on someone to do the job, get them to do it, and pay up.
What I don’t do is tell the panelbeater how to assess what needs to be done, what tools to use, what materials to buy to do it, or how to judge whether it’s completed. Even if I needed a lot of repair work done on a regular basis, I still wouldn’t tell the panelbeater how to do his job, or what constitutes ‘a good job’. Halfway through the job, if the panelbeater tells me that it’s going to take longer because a problem that couldn’t be detected originally has been found, I can’t decide that I’m not going to pay, or I’ll only pay the original estimate.
I need to be informed by, and consult with the professional when it comes to car repairs (and a whole lot of other stuff too!).
People with pain problems are not quite as simple to work with as a dented car. In car repairs the car doesn’t play a very big part in the process of being repaired. It simply sits there and the job gets done. In pain management, the person who is being treated has to be engaged in the process of developing skills that:
- Might not be recognised as needed
- Probably involve periods of pretty hard work involving negative emotions and thoughts
- Won’t produce immediate results
- Go against the ‘received wisdom’ that pain can be ‘fixed’
- Need to be integrated into every part of the person’s life, not just ‘at work’, or ‘at home’
At the beginning of therapy, it’s not always clear just what might influence how quickly the person reconceptualises their pain problem and begins to use the skills in pain management. It’s often not clear about the way that internal and external factors might affect how readily the person manages to adopt new approaches to life with pain. Things complicate pain management – low mood, other health problems, issues to do with returning to work, past history. The person may not even want to learn how to do pain management!
All of these various influences make the process of pain management a professional’s job, not a process. Oh if it were only so simple as following a recipe!
So when I heard that ‘payment by outcome’ was on the cards, I started to really worry.
Payment by outcomes assumes some things about healthcare:
- that financial incentives will motivate behaviour change in clinicians
- that these behaviour changes will deliver the outcomes wanted
- that policy makers can distinguish between those aspects of clinical activity that would benefit from financial incentives and those that would be affected adversely
- that the net benefits outweigh any unintended and unwanted responses (Mannion & Davies, 2008)
Hmmm. Does it really take money to motivate me to deliver good health care? If that were so, would I be working where I work? Even if I directly benefited from achieving certain outcomes (and that’s not likely in a public healthcare facility), is this what motivates me to do my best? Does a non-health professional really know which parts of clinical activity count in achieving the outcomes? What about unintended consequences?
Mannion and Davies suggest that there can be unintended consequences from payment by outcome.
• Tunnel vision—a focus on aspects of clinical performance that are measured and neglect of unmeasured areas It’s a whole lot easier to measure the number of patients seen than the quality of supervision. For an outcome-based payment system, it assumes that the outcomes being measured are those that count toward recovery. In a worker’s compensation system, this could mean measuring how far someone can walk, and whether they return to work, while ignoring monitoring their relationship with their family, and resolving their ambivalence about returning to work.
• Adverse selection—the incentive to avoid the most severely ill patients. If one provider works with especially challenging clients, will the ‘payment by outcome’ reflect that additional challenges? Or will providers start to select patients with low risk profiles?
• Erosion—the potential diminution—of intrinsic professional motivation as a key attribute of high quality health care. Something that characterises most health care providers is their own motivation to do well. Let’s not lose this in health, it’s a human element in an often impersonal world.
• Inequity—creation of perverse incentives to exclude disadvantaged groups – This results from choosing patients who are relatively ‘easy’ to work with. Those patient who are challenging are often this way because of other situations in their life – comorbidities, low socio-economic status, different ethnic groups – and they may well be disadvantaged because it’s more difficult for them to make progress. (Mannion & Davies, 2008)
The major influences on health care delivery are not necessarily based on evidence – it’s about who pays and how they pay. Policy makers and health economists need to consider multiple factors when determining the best way to obtain effective outcomes for people who benefit from their purchasing decisions. It needs to be a consultative process where the points of view of health professionals are considered. The details of how an intervention is achieved should be decided by health professionals. What that outcome should look like should be informed by science-based evidence as well as other ‘stakeholders’.
And payment by outcome needs to be very, very, very carefully considered because unlike a car repair, there are people involved, in all their complexity .
R. Mannion, H. T O Davies (2008). Payment for performance in health care BMJ, 336 (7639), 306-308 DOI: 10.1136/bmj.39463.454815.94