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The Argument Against Reimbursing Physicians for Value

Lara Goitein, MD1
[+] Author Affiliations
1Pulmonary and Critical Care Medicine, Christus St Vincent Regional Medical Center, Santa Fe, New Mexico
JAMA Intern Med. 2014;174(6):845-846. doi:10.1001/jamainternmed.2014.1063.
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Since the time of Hippocrates, it has been assumed that a physician’s first obligation is to provide the best possible care to individual patients, without distortion by competing societal interests.1 This once near-sacrosanct principle is being tested by the high costs of the health care in the United States, which increasingly threaten the economy. Because physicians control much of the delivery of health care, they have a natural role in helping to control health care costs. But historically, our society has been uneasy about assigning this role to physicians. When people are sick and helpless, do they really want their physicians to be influenced by costs, or do they need to believe that their physicians want only to serve them according to their medical needs?

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I agree with the author's main points, but.....
Posted on May 5, 2014
David L. Keller, MD
Conflict of Interest: None Declared
The decision \"to provide less or cheaper care\" will not \"end up being based on the belief system (or susceptibility to financial incentives) of individual physicians\" for the increasing percentage of employed physicians. Providing less or cheaper care will be mandated by management executives, driven a powerful double incentive: spending less contributes dollars directly to the bottom line, and the cost savings result in additional \"value\" bonuses from Medicare and insurers. Those dual incentives will certainly be passed through to physicians, and are the reason that physician compensation based on \"salary, without bonuses or withholds\" will not be implemented by most organizations which employ physicians. My second observation is that one cited study reported that \"in many geographic areas, higher spending is associated with worse health outcomes\", but another study reported \"that lower spending at the patient or hospital level is associated with poorer outcomes for patients\". The association between higher spending and worse health is counter-intuitive, while the association between lower healthcare spending and worse patient outcomes comports with a belief in modern medicine. How can these opposite outcomes associated with healthcare spending be reconciled?
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