February 2007 | Back to Table of Contents

Perspective

Performance Anxiety

By John Eikens, M.D.

A physician questions whether prescribing a new drug will benefit his chance of a bonus more than his patient.

Harvey Broadman* (*the patient's name has been changed) is in my clinic today for his diabetes check. He is 57 years old and retired from his job as an over-the-road trucker. I met Harvey six years ago on the day he was diagnosed with type 2 diabetes. He is currently on three medications: two for diabetes and one for high blood pressure. I would not describe Harvey as a health nut.

As I review his lab reports, my heart sinks a bit. Unfortunately for both Harvey and me, his LDL, or bad cholesterol, is 154. His LDL goal was clearly established at less than 100. Knowing Harvey, I think it is unlikely that he is going to alter his diet enough to meet the goal. He has already seen a dietician twice since his diagnosis. Slowly, I launch into my canned speech regarding bad cholesterol. The speech is relatively short and rational. It ends with the suggestion that we can start something that I think will almost certainly solve the problem—a statin drug.

I want the best for Harvey. He is a bit of a tough sell, though. It was already a stretch to convince him to add the second diabetes drug, a drug that is expensive and without a generic equivalent. I know Harvey has limited resources, and I know his first priority is not always his health. Unfortunately, none of the statin drugs I use are particularly cheap, and the number of people who experience side effects from them is high.

I like to think I can be convincing when I make my health care recommendations. Twenty-three years of experience have given me just the right touch when it comes to convincing patients that I’m giving them the right advice regarding their medical problems. I know just when to lay on a bit of guilt or back off and let the patient come to the conclusion that I already have.

Harvey is no different than most of my patients. He was initially reluctant to add the statin. But when he finally agrees to try the new drug, I’m relieved. Another small battle won, and another patient diverted from the cavernous hole called noncompliance.

Hidden Motives
There is something Harvey doesn’t know about our little exchange. I have a vested interest in seeing him take the new drug. It’s not that I get some kickback from the drug company; what is motivating me is much more subtle.

What Harvey doesn’t know, and what I suspect the average patient doesn’t either, is that a small part of my salary this year is based on how well my patients with diabetes stack up on mathematical parameters that have been generated by the large health care corporation I work for. One that is being looked at for my patient population is LDL cholesterol. If I can get Harvey’s LDL below 100, there is a slightly better chance that I will get what I would consider a small, but certainly not forgotten, bonus. I assume my employers would not offer me the money if they did not think it would alter my behavior.

I am not immune to financial forces. I could feel my resolve strengthen when Harvey initially brushed off my suggestion of a new medication. I explained that if we could keep his LDL low and his other parameters in line, we could assure him we were reducing the statistical chance of his death and other complications of diabetes. I try to keep this in mind as I send his new prescription to the local pharmacy. But I am left wondering whether I was prescribing the medication for Harvey’s benefit or mine.

This new development in health care is called pay for performance, and my performance, now that I use an electronic medical record, is only a few clicks of a mouse away from those who watch over such things. It is not limited to LDL determinations in patients with diabetes. It is tied to a number of health parameters, many of which are influenced by the patient’s lifestyle. But experience tells me that the numbers will be better if I spend my time manipulating pills rather than trying to get patients such as Harvey to change his habits.

Harvey lives in a trailer located within a stone’s throw of the local interstate highway. He has no prescription drug coverage and is unsure if he would rather have the pills or the money. Harvey may be unsure, but pay for performance is clear regarding the best course of action.

When he came back for a subsequent visit, Harvey’s LDL on my newly prescribed drug was 104, which was close to but not quite at his goal. He was already experiencing mild muscle aches, a common side effect of this type of pill. Once again, I felt the impulse to add more medicine, this time in the form of an increased dosage. Harvey’s muscle aches were minor, and to some degree they could be tolerated. As I prepared to raise the dose, I had a more sobering thought—What if tomorrow’s paper reports research linking statin drugs to a more critical side effect such as cancer?

Gospel or Greed?
If pay for performance is a religion, then we are its evangelists. We know what is best for the patient. We know that length of life and reduction of complications supersedes all else in our patient’s world. It is more important than the patient’s financial status, their own desired level of aggressiveness regarding their disease state, their feelings about taking medications, and their proximity to death.

By tying these parameters to compensation, my employer has very effectively improved the organization’s overall performance in an even larger arena—the new world of performance-based competition among health care organizations. Future insurance contracts may be awarded to my organization based on our clinical results.

Of course, Harvey is not interested in that; but his insurance company is. Health care is getting more complicated all the time, and sometimes I am not sure who I really am working for—myself, my organization, the insurance company, or Harvey. MM

John Eikens is a family physician at Fairview Lakes Medical Center in Wyoming, Minnesota.