Managed Care Sources of Evil (and P4P, or Pay for Perdition)

Sandra blogged about Philip Zimbardo's post, Situational Sources of Evil, about Milgram's studies from the 1960s and the 10 behavioral methods or steps which are used to get good people to do bad things. As I read this, it made me think of the failed promise of Managed Care, and the next evolutionary change in U.S. medicine, Pay For Performance (P4P).

Here are my tangential thoughts about these 10 steps, as they relate to the whole managed care experience.

1. Prearranging some form of contractual obligation, verbal or written, to control the individual’s behavior in pseudo-legal fashion. In Milgram’s obedience study, subjects publicly agreed to accept the tasks and the procedures.

Managed Care (MC) involves establishing contracts with physicians and other health care practitioners, detailing what they can do and cannot do, in a manner which makes them look like poor sports if they do not comply (e.g., being
labeled a nonparticipant versus being part of a network of participating providers).

2. Giving participants meaningful roles to play — “teacher,” “learner” — that carry with them previously learned positive values and automatically activate response scripts.

We health care practitioners strive to provide good care and most are in it to help people, not just for money; so the idea of making health care affordable makes sense. How could we be opposed to this?

3. Presenting basic rules to be followed that seem to make sense before their actual use but can then be used arbitrarily and impersonally to justify mindless compliance. The authorities will change the rules as necessary but will insist that rules are rules and must be followed (as the researcher in the lab coat did in Milgram’s experiment).

Initially, there were rules limiting admissions to only those which were "medically necessary". Who wants to admit someone for a medical problem when it is unnecessary? Now, "medically necessary" is not what you think it is, but what the company defines it to be. Other rules get changed, and many have come to believe that "rules are rules and must be followed". Example: Dinah's previous point that Husband thought he must go to Lab B to get test done (even Lab A told him so), rather than paying the $12.68 and getting it done at more convenient Lab A.

4. Altering the semantics of the act, the actor, and the action — replacing unpleasant reality with desirable rhetoric, gilding the frame so that the real picture is disguised: from “hurting victims” to “helping the experimenter.” We can see the same semantic framing at work in advertising, where, for example, bad-tasting mouthwash is framed as good for you because it kills germs and tastes like medicine.

"Managed care" rather than "managed costs".
"Authorization" rather than "rationed care".
"Medical necessity" rather than "only if we want to pay for it".
"Referral" rather than "gatekeeper".

5. Creating opportunities for the diffusion of responsibility or abdication of responsibility for negative outcomes, such that the one who acts won’t be held liable. In Milgram’s experiment, the authority figure, when questioned by a teacher, said he would take responsibility for anything that happened to the learner.

Care is denied via a Review Committee rather than Doctor Jones. By requiring that patients or physicians jump through hoops, such as getting an authorization, waiting on hold for 15 minutes to speak to a reviewer, or filling out a 3-page treatment plan for 5 more visits, the guilt may then conveniently lie with you for not following the proper procedure, rather than the company for denying or limiting care.

6. Starting the path toward the ultimate evil act with a small, seemingly insignificant first step, the easy “foot in the door” that swings open subsequent greater compliance pressures. In the obedience study, the initial shock was only a mild 15 volts.

It started out as simple as "You accept less of a fee, we will send you more patients." Then it progressed to "You must accept whatever we offer, or we will send you no patients." Now it is "You must practice the way we tell you to, or we will send you less money (and imply that you are practicing substandard medicine).

7. Having successively increasing steps on the pathway that are gradual, so that they are hardly noticeably different from one’s most recent prior action. “Just a little bit more.”

Provide the diagnostic code.
Provide the diagnosis and treatment plan.
Provide the diagnosis, treatment plan, and copies of your progress notes.
Provide the diagnosis, treatment plan, copies of your progress notes, and also various evidence of measures of "performance" to prove that what you are doing can be shown to have a measurable impact on visit-to-visit progress (the equivalent of focusing on quarterly shareholder profits rather the big picture of what is best in the long run).

8. Gradually changing the nature of the authority figure from initially “just” and reasonable to “unjust” and demanding, even irrational. This tactic elicits initial compliance and later confusion, since we expect consistency from authorities and friends. Not acknowledging that this transformation has occurred leads to mindless obedience.

We started out with "medical privacy", which is every patient's right. Then we passed a privacy rule, HIPAA, which makes your records "more private" by removing requirements for you to authorize their release under numerous conditions, and even requiring you to give them up to law enforcement officials, without a search warrant. And, if national security is invoked, y then it is illegal for you to tell your patient that, "Oh, the FBI came by to look at your records." We are all so confused that mindless obediance has been achieved (e.g., annual "Privacy Notices").

9. Making the exit costs high and making the process of exiting difficult; allowing verbal dissent, which makes people feel better about themselves, while insisting on behavioral compliance.

Try "opting out" of Medicare... it means you can't work for anyone who wants to bill Medicare for your service.

10. Offering a “big lie” to justify the use of any means to achieve the seemingly desirable, essential goal.

The Big Lie: We will pay you more for practicing evidence-based medicine, which results in better performance. (The Big Truth: We will pay you less for straying from our population-based, cookbook procedures. As Scott Aaronson says, "The plural of anecdote is not evidence.")

Rate-A-Doc

Roy is working on a very nice post about the newest trend in medicine, Pay-For-Performance. We went to an excellent seminar about it this morning, so I'll let him do the honors of a formal recap. I just thought I'd put up some quick knee-jerk reactions to the whole thing.

The idea of pay-for-performance is that doctors will be monitored with regard to various yet-to-be-defined standards of health-care delivery and rewarded (or not) in response to adherence.

First of all, the thing that struck me was that everyone agreed that doctors needed to be measured but so far no one can agree on a ruler. Multiple governmental agencies, health care businesses and professional organizations have a finger in this pie but so far no one has pulled out a plum. There were obvious things discussed like requirements for proper physical assessment or laboratory monitoring, patient education, continuing education and the like but as each aspect was brought up there were parallel problems involved with the assessment. My favorite example: a proposal to make family involvement in patient care a benchmark. OK, sounds good. In prison? The family involvement we get there is the accidental kind, where they happen to meet in a holding cell. Another benchmark: proper referrals for psychotherapy (got any therapists handy over there in maximum security?).

But the main issue as I see it is that the physician becomes the sole endpoint of a very complicated healthcare delivery system. Adherence to practice guidelines could be a useful measure of healthcare quality, but what if the patient doesn't want to take those medicines? Or if you've already been through the guideline decision tree (meant, after all, for the easiest case scenarios which are never the ones I get)? There are just too many 'what-if' scenarios to really tailor one quality measurement system---an inpatient unit is different from a partial hospitalization program, which is different from an outpatient clinic which is different from an emergency room. And none of the guidelines or benchmarks even considered the possibility of a correctional environment.

Consider this: the state saves money by not providing resources to the health care provider. They set the benchmarks, then fine the health care company for failing to meet the benchmarks that they have not provided the resources to obtain. A financial win-win situation for the state. Now comes pay-for-performance, the dynamic now trickles down to the level of the individual clinician. The question that I asked the presenters---and which brought the room to a dead silence---was whether or not the P4P approach would lead to any requirement that publically-funded health care systems actually provide the resources to meet their benchmarks. If so, sign me up.

In the meantime, I can't wait for my final benchmark: the patient satisfaction and quality-of-life survey. Of course, in my situation that would be the quality-of-life-sentence survey.

Economist Suggests Changes to our Health Care Delivery System: P4P vs P4V

I posted briefly about Pay-for-Performance (P4P) efforts earlier, describing them as the next step in attempts to reduce health care costs while wrapping it up in a package to make it look like an attempt to improve quality.

I remain skeptical that this is the wrong approach. Insurance company bureaucrats will have us "teaching to the test" in the same way that primary education has gone... and with the same disastrous outcomes, I fear. Kids can answer the questions, but can they think? Do we want doctors who just focus on keeping hemoglobin A1C's down, speeding up the time that you get the first antibiotic during abdominal surgery, and counting up the number of cardiac patients they have on beta-blockers? Will we get lost in the forest, just tending to the trees?

Harvard economist, Michael E. Porter, in last week's JAMA, addresses P4P and broader health care delivery issues in a manner which I find very appealing. It places physicians back at the table, while holding us and others accountable for adding value by collaboratively focusing on patient outcome (not process) to improve patient care while controlling costs. In the article, How Physicians Can Change the Future of Health Care, he describes an approach to competitive, cost-effective health care that places the patient back in the center (isn't that what it's all about?), while teams of health care providers work together in parallel (not serially) to address each patient's needs as a connected team, not as an assembly line product. This is apparently what M.D. Anderson and Mayo have been doing for some time.

Take a look at this article and see what you think. If you can't get access to the whole document, email me at mythreeshrinksATgmailDOTcom, and I could send you a few pertinent paragraphs for educational purposes only (for the purpose of comment and criticism). (Or, get his book.)

P4P

Dr Rob over at Musings of a Distractible Mind blogs about the next big thing in sticking it to patients and providers in the name of shareholder profits: Pay For Performance. He explains the new acronyms, plus a few more (I like P4Poop).

He really nailed Psychiatry.