Rewarding results?

Dr. Gary J. Young probably doesn’t know you or your doctor, but his work may decide whether your doctor will one day get a bonus for keeping you healthier.

Young, an associate professor in the School of Public Health, and his nine-member research team have been hired by the federal government to the tune of a $250,000 grant from the National Institutes of Health to give the ‘Rewarding Results’ program a complete physical: a comprehensive, four-year assessment of if, and how, it works.

‘Rewarding Results’ is an $8.8 million program aimed at improving the quality of American health care by giving health care providers both financial and non-financial incentives to meet certain quality-of-care benchmarks, according to AcademyHealth, a Washington, D.C.-based health policy thinktank.

‘The federal government and some of the leading private foundations in health care pulled this project together … to test different ways of providing [health care] providers incentives … to improve the quality of care they provide,’ Young said. ‘I guess to the [average person] what this really means is that the providers that they’re seeing may have explicit incentives, financial incentives, to hopefully improve the quality of care they receive.’

According to Young, the program was born of recommendations in a 2001 report penned by the Institute of Health, a private, non-governmental organization associated with the National Academy of Sciences.

Young said the report, titled ‘Crossing the Quality Chasm: A New Health System for the 21st Century,’ paints the tug of war between quality and quantity as one of the fundamental problems with the American healthcare system a system that he said devours nearly $2 trillion a year and in which, a previous Institute report alleged, 100,000 die annually from medical accidents.

That earlier report, titled ‘To Err is Human,’ sparked what would eventually become ‘Rewarding Results,’ Young said.

‘There was a tremendous response to that report from the public, calling Congress, demanding that more money be devoted to figuring out why so many errors occur,’ he said. ‘People have disputed those numbers – there have been follow-up studies that have said it’s much less than 100,000 – but the idea that a 100,000 people a year are being killed in hospitals due to accidents had a very visceral effect.’

Young said the 2001 report offers quality incentives as part of the solution to the problem.

‘I think [the Institute’s] conclusion was that the system is broken, and that the quality of care is nowhere near where it should be,’ he said. ‘And one of the recommendations they made was that the way we reimburse [health care] providers is completely out of sync with good quality of care because we reimburse them for productivity, but we don’t reimburse them at all for high quality.

‘And compared to other industries where quality matters to consumers, in this country there is just no mechanism for reimbursing providers for providing good quality care.’

That’s where ‘Rewarding Results’ comes in.

‘For example,’ Young said, ‘if a physician has a panel of women [and] a certain number of those women are over the age of 55 and thus considered to be candidates for mammography screening, the performance target might be 80 percent of all women who are candidates for mammography undergo screening during the course of a year. And if you hit the target you get a cash bonus.’

But according to Young, the program doesn’t just offer bonuses. He said other incentives called ‘withholds’ could result in doctors being penalized for not reaching certain quality quotas. He also said the program has the most potential to save money, suffering and lives relating to the treatment of chronic illnesses like diabetes and asthma. Better-managed care, he said, keeps people healthier and helps preempt expensive hospital stays.

With the program currently being implemented in six experimental sites across the country three in California, one in Michigan, one in Rochester, N.Y., and one in Massachusetts Young has been enlisted to help make sense of all the data and conclude whether ‘Rewarding Results’ is as rewarding as some believe it is.

His research began in September, when he was awarded a $249,886 grant from the National Institutes of Health and the Agency of Healthcare Research and Quality, and it will conclude four years from now with a series of reports and ultimately a book, he said.

In between, Young and his team will usher the various participants some of the largest insurance companies in the country, including Harvard Pilgrim, individual physicians, groups of physicians and hospitals through the trial process, collecting volumes of insurance claims and medical records data along the way.

‘They’ve hired us to serve as a national evaluator, which means that we have a responsibility for working with all these experimental sites to ensure the scientific integrity of what is being done and how it is being evaluated,’ he said.

‘And really, at the end of the day, our responsibility will be to look across all these experimental sites and draw some lessons that can be learned by pooling the experiences of these experimental sites. Because this is all supposed to be a whole laboratory of new ideas; it’s not a matter of ‘did it work, yes or no?’ But more subtly as a matter of what you can really learn from this…to provide a foundation for policymakers in the future to think about reimbursement systems can be adjusted.’

He said the project will conclude with a survey of the providers involved in the experiments to gather their perceptions of the incentives.

And while Young said that the shape of the research how his team will collect and evaluate the data from the various sites is still being worked out, he clear about the focus of his work.

‘The question is: is providing these kinds of explicit financial incentives a good thing?,’ Young said. ‘Over the last ten years, with the whole dot-com era, there was big push to reward employees on the basis of incentive stock options, and not too long ago most self-respecting economists and consultants were telling companies that that’s the way to go because that way you align the incentives of the employee with the company owners.

‘We now know, after Enron and WorldCom, that these incentive stock options in some cases led to some unexpected and perverse behavior. Managers became very short-term oriented, and [these incentives] drove companies to focus only on improving short-term share value and led to cooking the books.’

According to Young, such incentives could also lead doctors to focus only on improving their care in areas where they will receive bonuses, causing them to neglect other, equally important areas.

‘It’s like being a student in class,’ Young said. ‘The professor says, ‘Well, this is what I want you to focus on for the year: A,B,C and D.’ That’s where the students are going to put their time; that’s where students are going to put their effort.

‘What happens when providers are given explicit financial incentives to focus on A,B,C and they say, ‘Well, yeah, I used to spend some time thinking about D,E and F, but I’m not going to.’ What gets left out? You can’t create a set of incentives that’s going to be able to hit on every area that a provider should be focusing on, so you end up selecting a few areas that you think are most important, but what happens to those things that aren’t getting rewarded explicitly?’

That’s what Young’s research will try to determine.