These bonuses for doctors create an immoral conflict

Opinion by Gina Piscitello

“I want to eat again, do you think I can do that, Doctor?”

A patient with newly diagnosed stomach cancer understandably had immediate questions about his health and future. He was concerned that he may never be able to eat food again due to the cancer, which was now so large it obstructed the entrance to his stomach.

He was trying to appear strong, but I could tell he was scared as he understood he was nearing the end of his life.

As the palliative care physician caring for him, I discussed with him his options for medical care such as considering a feeding tube and transferring to a rehabilitation facility versus going home with hospice care and significant family support.

“What does a feeding tube look like?” he asked. “Will my insurance cover it? Will my family be able to afford time off work to care for me if I choose to go home?”

He had many questions; I knew he would benefit from discussing them further with me. I also knew he was concerned about hospital costs and my visits with him may increase those costs.

Of course I wanted to help, but I also knew that seeing this patient again could financially benefit me depending on where I work. I wondered if personal physician financial incentives could unconsciously influence my decision to see patients like him again.

I am not alone in this concern.

In the US, many physicians receive financial incentives, created by individual hospitals and medical groups, based in part upon the number of patients seen. The intended goal is to encourage physician productivity and improve patient outcomes.

Yet, I admit, these financial incentives have ethical concerns as they can directly influence the behaviors of physicians and tie in quality patient care directly with physician profit. That profit carries a cost to patients and presents a conflict for physicians: Is the care I offer as a physician truly going to benefit each patient, or am I seeing patients to increase the number of patients I see?

Many physicians’ bonuses, 73% per data from 2019-2020, are tied to relative value units (RVUs), which measure time, skill and effort for each patient a physician sees. Fewer physician bonuses are tied to quality-of-care measures, or protocols and processes that encourage increased patient safety measures and decreased death rates.

It is an ages-old quantity vs. quality debate, but with lives in the balance.

To be sure, RVUs are an important measure of physician work and expertise. However, these units alone do not account for the true quality and value of care physicians provide to patients.

For measurement of RVUs to be the most frequent financial incentives method for physicians is wrong. Incentives based on these units can and will increase patient costs, as physicians will be incentivized to see more patients, potentially even those without true medical indications for their physician care, instead of focusing solely on improving patient health and outcomes. This structure leads some physicians to intentionally see patients who medically do not need to be seen.

Medical costs in the United States are already exorbitant, with an average expense of over $2,600 per day of inpatient hospitalization, and they contribute to significant financial strain accounting for the majority of bankruptcies in the US. Even though the US spends more on health care than other high-income countries, we often have worse health outcomes.

Incentivizing RVUs also may lead to abuse of medical trainees, who may be instructed to see more patients than is beneficial for learning, which financially benefits their attending physicians.

What’s more, this incentive system negatively impacts the value of care physicians can provide. For example, as palliative medicine physicians, we often must spend significant time with each patient to build trust that allows patients and families to discuss life and death decisions with us.

Incentivizing palliative medicine specialists to spend less time with each individual patient so they can see more patients negatively affects the relationships and the care we can provide these patients.

Instead of an RVU-based structure valuing volume of patients seen, physicians should be incentivized to provide medical care of high quality. This high-quality care produces beneficial and measurable outcomes — such as decreased intensive care unit costs and reduced hospital readmissions — which can be used in financial incentive plans.

For the patient with stomach cancer, I know I made the right decision by seeing him again, but I continue to feel guilt that, depending on where I work, I may financially profit from visits like these which increase patient hospital costs. My goal was to improve his quality of care, not to increase the number of patients I saw that day.

But as long as RVUs remain a predominant structure of financial incentives for physicians in the United States, physicians will experience this same conflict between wanting to provide high quality patient care and being financially incentivized to see more patients.

It is immoral to allow this conflict to occur. If physician financial incentives are to exist, they should promote quality and value in patient care. Individual hospitals and medical groups should be prohibited from choosing physician incentive measures which prioritize volume of patients seen over quality of care.

Quality over quantity must be the driving force in medical care.