They made me do it!

After reading this excellent study in the BMJ showing no benefit and some risk of harm from annual mammographic screening for breast cancer (see also this discussion in the NY Times) I suggested to a local institution that they should reconsider their Pay for Performance (P4P) initiative which penalizes their clinicians (by lowering their pay) if their female patients over 40 do not have regular mammograms. 

The response I got unnerved me. Rather than a discussion of the potential value or harm of mammography, I was told that this is not the point:

“(the health care institution)…is no longer in the business of making decisions…it is now directed by payors and insurers and as a result, passes along those rules to its employees…(one) no longer (has) an employer who can decide the strategies of the organization.”


First: I get it. I co-founded and then co-owned and managed a private practice for 3 decades. I don't for an instant deny the turbulence or financial threats in the medical arena.  I just don't buy that any institution is entitled to play the victim card this way. It’s an irresponsible and childish cop out. Which brings me to...

Second. It is simply not true that institutions are no longer in the business of making decisions. When an institution says that the risk/value analysis of mammography is secondary to the financial impact of reaching performance targets, it has made the decision that being fiscally sound trumps being medically sound. This is a decision. It may be a good decision or it may be a bad decision, but it is a decision.

I would frame this decision as a choice between:

  • Prioritizing the medically most sound policies, and then working really hard to function in that context.
  • Prioritizing fiscal health, and then trying to provide whatever health care is possible within the policies and  constraints of payors.

I present these here as a binary, black and white, either/or choice, but obviously in most circumstances the choices represent antipodes of a spectrum.

I also understand that it is normal (and appropriate) for an organization to have self-preservation at the top of its list. (People tend to be that way as well.) I read a discussion long ago that said when a family that makes shoes becomes a business that makes shoes, making shoes moves from job one to job two, and keeping the business afloat becomes the new job one.

In this sense, I see this kind of institutional behavior as expected, normal, understandable and perhaps even appropriate.  But I also see myself as the advocate for my patient (as an individual) and for patients (as a class) in a way that I do not expect institutions to be. This dialectic is necessary, which is good, because it is also unavoidable. What saddens and frustrates me is that large institutions tend not see alternative perspectives and challenges to their decisions as opportunities for discussion and growth, but as disloyalty, disruptive and undermining the institution, and a threat to be quashed. It is especially distressing to see and hear intelligent, caring, motivated people buy into this. Hannah Arendt would see this as an example of the banality of evil.

Instead of simply serving as a conduit for external policy with regard to quality mandates, institutions should look at truly pursuing quality; projecting what the potential costs and outcomes would be, they could then in a public way talk about the tradeoffs on the table. I hear no public discussion of the money to be gained or lost by these various decisions, or of alternative ways to approach meeting targets, or of alternative approaches to survival without the money attached to the targets.

Institutions decide (there's that word again) to do what it takes to meet the targets. Then clinicians are left to try to advocate for patients as best they can.

Doing what is financially expedient (the boundary between necessary and expedient is a judgment call, not part of the natural universe) rather than what is right is the Enron way.  Following orders stopped being an acceptable defense after Nuremberg.

I don't value success at the expense of integrity. And I won't buy that institutions have no choice. Of course they have choices. They have both the right and the responsibility to make choices. But they also have the obligation to accept responsibility for the choices they make, without recourse to traditional elementary school playground excuses: "It isn't my fault. Everyone else does it. He told me to. They made me do it."

They had a choice. They opted for their current approach. Fine. They should stand up and say so. Something like: "Yes, we understand that some of these requirements are stupid, in some cases represent bad medicine, and may occasionally actually harm patients, but we need the money to stay afloat." Some would disagree that this was/is the only option, or even the best option, but everyone would have to respect it as a legitimate choice, honorably made, and transparently defended. 

"We have no choice" is not for grown ups with integrity.




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