The NEJM this week has an interesting article on the benefits of introducing economic incentives into medical practice. It's especially interesting because they overlayed these economic incentives on top of the British socialized medical system.

They created a set of metrics to determine the quality of care that physicians gave, like controlling blood pressure in hypertensive patients, keeping diabetics' hA1c levels low indicating good blood sugar control, and maintenance of low cholesterol levels in at-risk patients. Overall 146 quality indicators were tracked for 10 diseases, organization of the practice, and patient satisfaction. Based on scoring of the physician's ability to meet the needs of their patients, the docs were given financial rewards for providing a higher level of care, with the expectation that a profit-motive would lead to better care.

The doctors were also allowed to exclude patients from the scoring if they filed an exception report explaining why a different standard of care was needed. For instance, in a terminal cancer patient, you might not be as concerned with keeping their blood pressure controlled, that shouldn't count against the doctor that they didn't decide to overmedicate unnecessarily.

The researchers reported that the experiment, still in its first year granted, was a success. However, after looking at the results, I'm not so sure.

Here's the breakdown.

1. The most effective way for doctors to increase their scores was by increasing their exception reports to eliminate patients that would hurt their stats (although not many did this).
   
   

   For reported achievement (Table 4), the factor with the greatest effect was exception reporting. An increase of 1 percent in the estimated proportion of patients excluded was associated with an increase of 0.31 percent in reported achievement.

   
   
   
2. Decreases in score were caused by seeing more patients, poorer patients patients, older patients and less-educated patients.
   
   

   Achievement was lower in practices with a high proportion of patients who were living in single-parent or low-income households or were 65 years of age or older. Achievement was also lower in larger practices and in practices with a high proportion of family practitioners who received their medical education outside the United Kingdom or were 50 years of age or older.

   
   
   
3. In doctors seeing these disadvantaged populations, exception reporting was increased (even though these reports could not be filed for any of those reasons)
   
   

   The rates of exception reporting were higher in Primary Medical Services practices and lower in practices with larger populations of elderly patients, patients with good self-rated health, and patients without any formal educational qualifications

   
   
   
4. The program also cost far more than anticipated, but did not, at least in the first year, significantly improve medical provided.

Interesting no? So the conclusions are, introducing profit-incentives puts doctors seeing more patients, less-educated patients, older patients, or poorer patients at a disadvantage, it encourages filing of false reports to protect the doctors stats, it costs a great deal more, and failed, at least in the first year, to signficantly increase quality of care provided (probably because the care was already uniformly pretty good).

While it's early yet in this program, not exactly a stunning start for trying to force capitalism back into socialized medicine.