Monday, 16 July 2018

Health incentives: don’t shoot the behavioural economists!

Pedro Rey

The debate on the allocation of (economic) incentives associated with the performance of health professionals has been relevant for a long time. A few months ago, VOX has published an editorial with a very clear title: Paying Doctors Bonuses for Better Health Outcomes Makes Sense in Theory. But it doesn’t Work. The article cites numerous recent studies, such as this one on the United Kingdom or the United States, that show no effect of giving incentives to physicians either in their clinical practice patterns (inputs) or in health outcomes (outputs). A systematic review of studies on "pay for performance" (P4P) in the Annals of Internal Medicine reaches similar negative conclusions. However, a marked anti-economist tone of these articles emerges that I believe comes from a confusion. According to these articles, economists only know how to prescribe the use of incentives, without evaluating their effects, and also the incentives that we advise are only monetary and don’t appeal to the many different motivations, not only monetary, that can affect doctors decisions.

My response to these criticisms is that they generalize and caricature the profession of economist. It’s obvious that there are many economists with media success or with political influence who talk rubbish, but we should stop listening to them (another day I’ll talk about how to discriminate between one type of economist and another). Not even the best economists would be inclined to recommend incentives based only on theoretical models without a previous empirical evaluation, ideally with randomized experiments. All economists have an extremely limited view of the human being (and the doctor) as someone for whom only financial incentives matter and therefore motivate them. The area of ​ Behavioural Economics, which a growing group of economists are working on, studies precisely the multiplicity of human motivations, as well as our cognitive difficulties to make "correct" decisions in situations of pressure. Both the multiple motivations and the fact of having to make decisions, literally of life or death under stressful conditions, are common characteristics of the day to day of the health professional. Designing incentives that really motivate and guide the doctor to make good decisions is therefore a crucial part of behavioural economists’ work, and not only of the so-called health economists. In the article "When and Why Incentives (Don’t) Work to Modify Behaviour", we review the use of incentives in very similar areas such as education or the creation of healthy habits. Perhaps some of these lessons can be applied to incentives for health professionals.

The problem in the indiscriminate use of monetary incentives among professionals is that at first glance, it seems to respond to that logic of domestic economy that our president, Mariano Rajoy, likes so much: "the more I get paid to do something, the harder I will try and be better at my job". Let's analyze the problem of these three phrases applied to the health field:

  1. "The more I get paid": it’s not very clear that any health system, moreover a public one, can offer monetary incentives high enough to compete with the pharmaceutical and health technology industries. In an environment in which these institutions combine financial capacity with very clear and biased interests so that the physician can make decisions that favours them, it doesn’t seem very effective to start an upward race to see who can guide the price to a higher level so that the most convenient decisions are made. As the title of one of the articles by one of the key economists of Behavioural Economics,  Uri Gneezy says, "Pay enough or don’t Pay at All". The problem is that we may never be able to pay "enough" to offset the incentives offered by institutions with other interests. But, beware: the possible motivations of doctors are much broader than simply monetary ones. If these motivations are diverse (prestige and professional stability, the altruistic feeling of improving the patient's health, the good image that a doctor projects towards others ...), so should the possible incentives that, properly designed, can be given to get a better performance from the professional. The health manager should realize that many other tools at his disposal also involve powerful incentive mechanisms for health professionals and can help, if used in a systematic and thoughtful way, to greatly improve performance: job stability, flexible scheduling, greater independence in decision making depending on results, possibility of training in other centres and other techniques, facilitating the ongoing contact with the treated and cured patients and greater transparency on the individual contribution of each doctor. In this recent study by Social Science and Medicine it’s shown that not even doctors who receive monetary incentives have greater job satisfaction than those who do not, so money doesn’t seem to be the only thing that motivates them. In addition, there is the classic problem of the possible negative interaction between different types of incentives: by giving a monetary incentive one can substitute the original motivation for which a person did his job well, for the economic motivation, which can have perverse effects and anyway, it makes it very difficult that once the incentive is withdrawn, the original motivation for "doing things right" is retained. For example, would you still be a blood donor if you were paid to do so from now on?
  2. "The harder I try": It doesn’t seem that the primary problem of the health professional is the of lack of effort. On the contrary, it’s not so clear what is translated "to try harder" when there are multiple treatment guidelines. Does the interventional surgeon make more effort than the one who decides on a more conservative treatment? Obviously, one can try to define the "appropriate" treatment, for example, through clinical practice guidelines and then study whether the doctors who receive incentives apply this method more, but even in such clear cases, the existing evidence clearly shows that Incentives work to change behavioural patterns of specialists with highly trained opinions on how to treat their patients. In many cases, resources are squandered by encouraging treatment guidelines that already exist, or the doctor who doesn’t follow the indicated pattern is penalized even in cases in which he should not do so simply because of the patient's individual character.
  3. "The better I do my job": The problem is even greater when we want to measure the effectiveness of incentives through results, such as health outcomes. In these cases, the problem is not so much in choosing the variable by which to measure the result, but in interpreting causally that this improvement has really been due to the change in behaviour of a doctor who receives an incentive. Separating historical effects, such as the evolution of a disease, is something that good economists could contribute with their econometric techniques as long as they had sufficiently rich data, ideally designed with an experimental approach, to do so. 

Therefore, the debate between managers and health professionals on the use of incentives should remain open, but should leave behind prejudices and listening better to what seems to motivate professionals. Neither economists only talk about "monetary" incentives, nor should doctors only worry about receiving more money. Let's be smarter by designing incentives that really appeal to the true motivations of the professional, to then evaluate their effectiveness (or lack thereof) according to the correctly defined objectives. 

Monday, 9 July 2018

Do we need audits or indicators to control the quality and safety of health centres?

Mª Luisa de la Puente 

Are care indicators useful in detecting the quality problems in hospitals? This question, which seems obvious, has its crumb. Alex Griffiths, of the School of Management at King's College London, has just published the results of a study of the usefulness of health indicators as predictors of the quality of care of English hospitals and the conclusion is that you can’t trust them too much.

The Care Quality Commission (CQC) is responsible for ensuring the quality of health and social services in England (more than 30,000 providers). Due to the scarcity of resources to carry out on-site inspections, the CQC used statistical surveillance through health indicators to prioritize those hospitals that had quality of care problems and subsequently send inspectors to these centres. The inspectors’ mission is to analyze the situation and give support to the suppliers for the orientation of the improvements. What was surprising to see was that the instrument "Intelligent Monitoring" (IM, scale of risk composed of 150 indicators, among others waiting list, mortality, surveys of users and professionals, etc.) is not able to predict which hospitals present quality problems or discern between those that work well and those that need improvements (compared to the classification of sanitary inspectors).

Monday, 2 July 2018

Improving the emergency and territory services: defragmenting the system

Xavier Bayona

In several articles of this blog you can read that one of the challenges to overcome in our and in most healthcare systems is the excessive fragmentation in health care that inevitably leads to duplication of tests and other dysfunctions that create pockets of inefficiency and malfunction. Several proposals to improve the continuity of care and reduce fragmentation have been presented with the aim of improving the quality of citizen attention, increasing the effectiveness and efficiency of the system.

Fragmentation is also present in emergency services. So if we look to the NHS, we can find a report published by the Royal College of Emergency Medicine with the Patients Association (Time to Act-Urgent Care and A & E: the patient perspective) published in May 2015, which concludes that primary care emergency services should join with those of hospitals. In this regard, as early as 2013, Bruce Keogh, medical director of the NHS, made the same recommendation. it’s commented within 2015 report that joint placement services should include emergency physicians, family physicians, nurses, frailty care, palliative care and mental health teams. It’s also commented that pharmacists and dentists could also contribute to the efficiency and effectiveness of the service.

Monday, 25 June 2018

The red line of health data

Elena Torrente

The great technological giants (Google, Apple, IBM or Microsoft) are recruiting scientists and experts in medical research. Their commitment to transform medicine is decided, but John T. Wilbanks and Eric J. Topol warn of possible risks in this interesting article published in Nature. Given the difficulties that medical research has always encountered in obtaining health data, the authors believe that it may be tempting for clinical scientists to access large-scale Internet projects, with significant data collection capabilities and algorithms for analysis.

But there is a risk that Google or other smaller companies such as 23andMe, will access health data with the aim of controlling the methods used to offer certain services based on digital profiles. This is what in other sectors of the Internet is called the society of the "black box". There are ads that are only offered to certain groups of people and if these algorithms incorporate health data, the authors say that pre-existing biases in our society would increase along with inequalities.

Monday, 18 June 2018

Vinay Prasad: Why is 40% of clinical practice wrong?

On May 18, Vinay Prasad offered a conference in Barcelona as part of the 5th "Right Care" Conference of the Clinical Management Section of the Catalan Society of Health Management (SCGS), where we had the opportunity to invite him to explain why he had created (with Adam Cifu and other collaborators) the list of 146 clinical practices that would have to be reversed and what are the criteria they had been used.

What is medical reversal?

According to Prasad, a medical reversal is the need to stop a clinical activity because a well-done study, usually a clinical trial with finalist indicators, shows that in fact, the desired results are not achieved, or that the adverse effects do not compensate the benefits. The speaker gave some very diverse examples, such as the Swan Ganz catheterization to monitor the hemodynamic balance of patients in shock, the hormonal treatment for post-menopausal women in order to reduce coronary or cerebral vascular risk and the placement of coronary stents in patients with stable angina to reduce the risk of infarction, increase survival or even to delay the effort angina. In all three examples, consistent clinical trials have shown that these were clinical activities that, in practice, did not meet the set objectives, and in addition had side effects, which were not unimportant.

Monday, 11 June 2018

Radiologists and incidental imaging findings

A group of radiologists from several American university hospitals (Massachusetts General, Cleveland, Brigham and Women's, etc.) started a debate in the Journal of the American College of Radiology about the eventuality that radiologists would stop reporting the incidental imaging findings lacking clinical significance. "The traditional role of the radiologist," they say, "is to warn of everything they see, leaving the interpretation of the findings’ relevance to the referring physician”. However, we now open the opportunity to go further, and not just intervene by saying, for example, that an observed abnormality is benign, but also taking the decision not to report the milder ones, given the possibility that our opinion generates confusion and ends up causing excessive medical actions".

Regarding level I renal cysts of the Bosnian classification

The radiologists who authored the article used the findings of renal cysts, which are very frequent with a prevalence of 36% in patients over 80 years of age, in order not to inform of renal cysts of level I of the Bosnian classification in their reports, in accordance with the following criteria: a) the cyst is not the reason for the examination, b) doesn’t generate local problems, c) has no malignant potential, and d) is not likely to generate a polycystic kidney disease.

Monday, 4 June 2018

Coronary Bypass and Hemodynamics: the amount matters

In the article "Comparing hospital performance within and across countries: an illustrative study of coronary artery bypass graft surgery in England and Spain", signed by a Spanish-English team in which Sandra García Armesto (IACS) and Enrique Bernal (REDISSEC) participated, it was concluded that the Spanish hospitals of the study operated in general with a smaller number of cases than the English (it was coronary bypass). Therefore, it is suggested that the number of cases intervened should be a tracer that could explain why mortality from this process is twice as high in Spain as in England.

European Collaboration for Healthcare Optimization (ECHO) is a European network of administrative databases for the analysis of clinical practice variations. In the following article: "Hospital Surgical Volumes and Mortality after Coronary Artery Bypass Grafting: Using International Comparisons to Determine Safe Threshold", carried out by almost the same authors as the previous one, based on data from the ECHO project, confirms that for interventions of coronary bypass there is a clear relationship between volume and mortality and concludes that the minimum limit of interventions of a cardiac surgery team, if you want to safeguard the safety of patients, should be 415 per year. In the following graph (from the previous article) it is observed how the Spanish hospitals that participated in the study (dark spots), generally underwent fewer coronary bypasses (many did not reach 200) and showed greater mortalities.