Tennessee doctors to get paid for "doing the right thing"

Health care quality improvement advocates believe that following evidenced-based guidelines, spending more time with patients and making better use of electronic medical databases will lead to better patient outcomes and lower costs.

A new study led by Vanderbilt University in Nashville, Tenn., and BlueCross BlueShield of Tennessee will put this theory to the test.

According to Tennessee Blues' Chief Medical Officer Steve Coulter, MD, doctors will be paid "for doing the right thing" and researchers will measure whether this improves outcomes without significantly adding to costs.

Physicians will be measured and compensated based on how well they adhere to evidence-based guidelines for treating congestive heart failure, diabetes and hypertension and for follow-up calls and e-mails to patients.

"The current system contains some perverse incentives: It rewards volume and procedural complexity; it doesn't reward low-intensity activities like phone calls and e-mails and following evidence-based guidelines," Dr. Coulter said.

The study will also integrate clinical and administrative databases, which will open up new ways to measure patient outcomes and compliance with physician instructions.

Dr. Coulter said that clinical records typically show a prescription was written, but it's the administrative records that show whether it was actually filled and then refilled. Likewise, administrative records show whether a diagnostic test was taken, but the results of that test are only available in the medical record.

"Merging these two databases will result in better patient care," he said.

Still figuring out the "right thing"

One thing the program will not do is hold doctors responsible for patient outcomes. Dr. Coulter said physicians will be measured for following guidelines, but it's the program as a whole that will be measured for outcomes.

"You can hold a physician accountable for doing the right thing, but you can't really hold him accountable for whether it works or not," he said. "That's really in God's purview."

Vanderbilt Center for Evidence-based Medicine Executive Director Paul Keckley, PhD, said work is under way to determine what constitutes "doing the right thing," including determining which practices will be called for and how often, and what incentives would be appropriate.

Dr. Keckley added that patients may also be included in incentive plans. "When treating hypertension, patient compliance is a more difficult challenge than physician compliance to guidelines," he said.

Dr. Keckley said the center is studying how physicians can be rewarded for increased patient compliance and how patient incentives may help, but he added that "the likelihood that 100% of the patient population will be totally compliant is nil."

Dr. Keckley said another problem the study seeks to address is the time constraints facing physicians. On average, they have just five minutes and 48 seconds to explain to patients their condition and treatment options and to answer questions.

"The clinician is challenged just to get their information out and is very challenged to answer questions," he said. "While the patient is often too ill-informed, intimidated or unprepared to ask the right questions."

One direction worth exploring, Dr. Keckley said, is building tools physicians can use to prepare this information in advance of the patient visit. The program also seeks to avoid adding to paperwork.

"This shouldn't add to the administrative burden of anyone -- that's my hope," Dr. Coulter said. "What we'll be doing is paying for things we currently don't pay for and we'll see if it results in better patient care."

It's been argued that the "business case for quality" -- proof that increasing quality reduces costs -- has not yet been made, and Dr. Coulter said he didn't know whether this program will change that.

"That's probably a bit grandiose, but my hope is that this will be one more piece of evidence that doing the right thing results in better outcomes and lowers overall costs," he said. "But the goal of the health care system is not to save money, it's to make people live longer and better lives."