Since the Supreme Court upheld the Affordable Care Act, policymakers and hospital management professionals have sought to curb rising health care costs while simultaneously offering care to more individuals nationwide. The idea is that more efficient health care will reduce costs, thereby enabling the government to use the surplus funds in the national health care budget to care for additional patients.

In an unprecedented step towards achieving this goal, the State of New York has just this week determined that doctors’ compensation at public hospitals in New York City will be directly tied to the quality of care they provide. Patient complaints and other elements associated with patient care–including the duration of patients’ hospital stays and patients’ health post-treatment–will directly factor into physicians’ paychecks.

The disastrous consequences this new policy could have for medical professionals if adopted are twofold:

1. Doctors may feel compelled to curtail treatments that might otherwise be beneficial to patients for fear that patient frustration will result in negative reviews, directly impacting physician compensation.

In an ideal world, holding doctors accountable to their patients will encourage them to become more efficient, thereby reducing health care costs across the board. However, we do not live in an ideal world. The missing link between lawmakers’ logic and reality is the fact that patients do not possess the medical knowledge necessary to effectively and accurately question the quality of care they receive. Those who believe doctors should include patients in the treatment selection process may disagree, but WebMD and its counterparts are not replacements for medical school or residency. Patients cannot know or be expected to understand the nuanced difference between treatment options.  Thus, to allow their opinions to directly affect doctors’ compensation could prevent doctors from exhausting all possible treatment options, which is the very point of health care in the United States (at least if you believe that health care is a basic human right and not a privilege). For example, should the duration of a patient’s hospital stay extend beyond what he or she would otherwise prefer for some inexplicable reason (which often occurs as doctors manage multiple conditions in patients at once), the threat of a complaint could force doctors to discharge the patient before they are ready for fear that continued care will adversely affect their paychecks. Doctors do not live in a vacuum: they have exorbitant levels of student debt given the amount of education they require. They therefore cannot entirely ignore their own salaries to go against patients’ wishes and provide the care they think is appropriate.

2. Patients are notoriously demanding in hospitals and could use their power of complaint to require hospitals to become five-star hotels.

As any doctor will indicate, patients’ complaints are never limited to treatment decisions. Rather, they include the quality of the facilities: cleanliness of the hospital, the friendliness of hospital staff, the sterile atmosphere of hospital rooms, etc. Should any aspect of their stay fail to meet their expectations, patients could threaten to complain to the State of New York unless hospitals provide better bed linens, televisions, DVD selections, food, and waiting rooms, among others. In explaining this reality, I do not intend to snub patients. Hospital stays, no matter how short, are never pleasant, and little upgrades in the facilities can make painful treatments more tolerable. However, allowing patients’ complaints to directly impact hospital reimbursements creates a slippery slope. Indeed, patients today may only want better TVs or linens, but patients tomorrow may want private rooms or gourmet food. At what point will hospitals and doctors be permitted to say, “Enough is enough!”? Failure to limit the impact patients’ complaints can have on reimbursements will surely result in higher health care costs as hospitals attempt to keep up with patients’ growing demands.

Therefore, while I commend New York on its effort to reduce health care costs, I strongly urge them to consider the ramifications of this policy from the lens of reality. In a field in which bad decisions could cause death, doctors need to have the freedom to select the medical care that is necessary without having to worry about the impact a disgruntled patient can have on their salary. They should never have to choose between providing for their own family and caring for others. Furthermore, patient complaints cannot be so tied to hospital reimbursements that hospitals feel compelled engage in something akin to an arms race to stockpile their facilities with the best amenities. There needs to be a better balance between the realities of providing medical care and patient feedback. It is my hope that New York lawmakers will consider this balance as they hammer out the details with doctors’ groups and hospitals.

– Swathi Padmanabhan

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2 Responses to “Doc, where’s my flat screen TV?”

  1. Amanda Nguyen says:

    I am wondering if there is some sort of middle ground. The pros seem obvious but often the cons are overlooked or explained away(like tying teacher compensation to performance.) Perhaps Katharine is right to suggest a sort of appeals system for doctors who receive bogus complaints. At the same time, wouldn’t tying doctors up with an appeals process negatively impact their abilities to care for patients. And, if taken to the other extreme, appeals could start to become de facto overruling of patient input, thus defeating the purpose. Certainly efficient healthcare and policy reform are necessary . . . but I would be hesitant to enact the measures NYC did.

  2. Katharine Skinner says:

    This is very interesting and I think your article brings up some great points. I read elsewhere that the performance indicators may range from things like how well the doctor communicates with the patients, to the rate that patients have to return after being treated one time for certain conditions. I really don’t know much about how the proposed plan would work, but it seems like there should be some sort of factual review of certain types of complaints so that patients can’t make unsubstantiated allegations. However, if there is indeed some sort of review, it seems to me that it would lead to a very time consuming, fact-intensive, and expensive inquiry process. For example, say a patient complained after having to return to the hospital when the treatment for a condition did not work the first time around. What if, in this specific context, this person would have had to return no matter what the doctor prescribed during the 1st visit – if for example the illness turned out to be more aggressive than indicated during the 1st visit (I know absolutely nothing about medicine so maybe this scenario is implausible, but based on general experiences with doctors it sounds possible). Could the doctor fight the complaint by trying to provide evidence that he met the proper standard-of-care requirements? Would he have to bring in another doctor who would testify that they also would have done the same thing during the 1st visit? Or provide evidence of this person’s medical records to show that the illness could not have been fully diagnosed during the 1st visit? While I think some performance indicators may be less controversial, like rating how well the doctor communicates with the patient, others seem like they could open the door for a very expensive and time-consuming process that would take doctors’ focus and time away from treating patients.