Correspondence

Doctor Discontent

N Engl J Med 1999; 340:649-653February 25, 1999

Article

To the Editor:

Neither Grumbach et al. in their article on primary care physicians' experience of financial incentives in managed-care systems (Nov. 19 issue)1 nor you, Dr. Kassirer, in your accompanying editorial2 have addressed the fundamental conflict that is inherent in our health care system and that underlies the dissatisfaction of physicians. Our patients wear two hats and thus have two expectations of us. As a community of consumers, they demand cost containment and value in their health care system, but as sick patients in our offices, they expect complete and unrestricted access to the full spectrum of specialty, hospital, and pharmaceutical care.

If we physicians must bear the burden of managing the health care dollar, we must find ways both to reward appropriate use of services and to balance this with measures that ensure high quality. Quality alone cannot drive an incentive system, since it bears no relation to the use of health care. An individual physician who provides the highest-quality care may use vast resources, potentially driving health care costs skyward.

If Americans are willing to tolerate escalating health care costs, physicians will gladly abandon the constant ethical dilemma of balancing overall health care expenditures with the needs of the individual patients for whom they care. However, if Americans are unwilling to tolerate rising costs, physicians will probably continue to work in a system that rewards appropriate use of resources. Perhaps the ultimate model needs to be one in which patients share some financial responsibility for their own use of health care services so that they begin to value the concept of cost-effective, appropriate care.

Kenneth R. Cohen, M.D.
Health First Physicians, Lakewood, CO 80228

2 References

1
Grumbach K, Osmond D, Vranizan K, Jaffe D, Bindman AB. Primary care physicians' experience of financial incentives in managed-care systems. N Engl J Med 1998;339:1516-1521
Full Text | Web of Science | Medline

2
Kassirer J. Doctor discontent. N Engl J Med 1998;339:1543-1545
Full Text | Web of Science | Medline

To the Editor:

The article by Grumbach et al. on the effects of financial incentives confirms the findings of previous studies of non–health care, industrial businesses. As research is performed in health care settings that have moved toward industrialized medicine, the many studies of industrial companies can guide us. Studies of the effects of incentives or bonuses are not new in business, although the use of behavior-shaping techniques among physicians is a relatively new phenomenon.

First, previous studies have shown that the effect of incentive plans in general is temporary, that they are demoralizing to employees over time, and that the use of these plans is less likely to result in productive managerial strategies than nonuse. Over two dozen studies have conclusively shown that the expectation of a reward results in lower performance than if no reward is offered. Applied to physicians, in general, these findings indicate that when the work requires more cognitive sophistication and open-ended thinking, people perform worse under incentive plans.1 In addition, relying on incentives to manipulate behavior does not solve the underlying problems. Whenever people think about what they will get in return for a specific behavior, they become less inclined to take risks, explore possibilities, play hunches, or consider incidental stimuli.1

Second, in reporting their findings with respect to physicians' satisfaction or dissatisfaction, Grumbach et al. unknowingly support the findings of previous research — that is, the factors that result in satisfaction with one's job are distinct from those that lead to dissatisfaction with one's job.2 Whether or not there is an incentive, physicians who are given the tools, encouragement, and responsibility to provide high-quality care and to satisfy their patients will naturally tend to be very satisfied. Physicians who work in an environment where there is never enough time, with pressure from supervisors and restrictive policies, will tend to be very dissatisfied.

Third, employment status does make a difference in physicians' perceptions, and Grumbach et al. admit that their study was based on perceptions. Although a very high percentage of physicians in the study reported experiencing pressure in their practices, a much smaller percentage felt it compromised the care they provided. As more physicians move from the position of owner or partner to that of employee or independent contractor, their ability to govern themselves in the practice of medicine will be diminished.3 This can result in dissatisfaction on the part of physicians and the belief that pressure compromises the quality of care.

Brent A. Fisher, M.B.A.
Loma Linda University Medical Center, Loma Linda, CA 92354

3 References

1
Kohn A. Why incentive plans cannot work. Harvard Business Review. September/October 1993:54-63.

2
Herzberg F. One more time: how do you motivate employees? Harvard Business Review. January/February 1968:26-35.

3
Fisher BA. Serf or citizen: physician status and organization structure. Physician Executive. July/August 1998:45-51.

To the Editor:

Reading the article by Grumbach et al. on financial incentives in managed-care systems forced me to recall some events in the recent history of medical practice. Fee splitting, which provided a financial incentive for primary care physicians to refer patients to specialists, was declared unethical and was eventually declared illegal. Now we are offering similar financial incentives to physicians to limit referrals — reverse fee splitting. Is this not a more unethical practice?

In the first case, physicians enriched themselves by providing more care to patients, albeit unnecessary care. In the latter case, patient care is potentially compromised in order to enrich managed-care executives and stockholders. I must admit that I am more than slightly confused about this paradox. Have our ethics changed so much in so short a time?

Harry S. Etter, M.D.
Whitefish Veterans Affairs Clinic, Whitefish, MT 59937

To the Editor:

I believe you understate the situation a bit in your editorial. Words such as “unhappy,” “dismayed,” and “frustrated” could easily have been replaced with “angry,” “dispirited,” and “hostile.” Many of us feel we were sold a bill of goods. As our friends enjoyed life, we studied our way through college and medical school. Years of long hours, low pay, and tremendous responsibility in internships, residencies, and fellowships were accepted as rites of passage. We were taught that the secret to good medical care was to spend time listening to our patients. Instead, we hear the economic hounds baying at the door of the consultation office, asking us to see more patients in an hour than we know we reasonably can. It is so difficult to repay our loans, support our families, and run our offices in the current environment. The explanation is the bottom line.

Never in our years of training did we have rotations on accountancy or running a small business. We remember no seminars on ICD-9. When did we parse the intricacies of Medicare and insurance regulations?

To survive, we have had to run faster and faster just to attempt to stay in place. We have, each one of us, become the Red Queen in Through the Looking-Glass, except that life is not so wonderful. We wonder, should we get that M.B.A. degree or trust someone else to make these complex business and regulatory decisions? We do not see our spouses and children, bound as we are to the yoke of perpetual medical motion.

Is this reasonable? Would you expect good medical care from someone trained as an accountant? Have we sold our souls to this business devil, never having read the contract? Is this just? Can we continue seeing more and more patients to satisfy our fiscal managers, knowing that the quality of our work must suffer and that the sanctity of our oath to our patients is being violated?

Osler would shudder, but the Red Queen would only smile knowingly.

David C. Squillacote, M.D.
Multiple Sclerosis Foundation, Fort Lauderdale, FL 33309

To the Editor:

I am one of the disgruntled physicians you describe so well. Even as a diagnostic radiologist, I am not shielded from the control of managed care. Daily we fight little scheduling battles, trying to explain to patients why they can come to us for their chest films but not their computed tomographic scans, or why someone failed to obtain authorization for their magnetic resonance imaging (MRI) studies. Often my colleagues ask me how best to evaluate a certain problem, only to find that the managed-care folks will not approve the studies. It is amazing how many arthrographic studies of the knee I am now doing because insurers will not authorize the much more diagnostic MRI studies. The list goes on and on.

I am fed up, and even though I am only 49 years old, I have already cut back to half-time. Within two years I will be fully retired. It is just no fun being a doctor anymore. But what really scares me the most is that as I get older, I will become a more and more frequent consumer of health care services delivered by disgruntled physicians who have incentives to give me less and less care.

Richard A. Kendrick, M.D.
Modesto Radiological Medical Group, Modesto, CA 95354

To the Editor:

As a young physician who, since finishing medical school, has been in California, where health maintenance organizations (HMOs) have a large share of the market, I strongly disagree with the suggestion in your editorial that younger physicians do not feel the current “anguish within the profession.” As a resident formerly and now a fellow, with a salary that is independent of the number of patients I see, I have been only moderately affected by the nightmare addressed in your editorial, yet I am still exceedingly frustrated by it. . . . We young physicians are forced to learn “billable diagnoses,” formularies for different health plans, key diagnoses for which medication costs will be paid, and insurance codes, in order to know whether we can order laboratory tests or studies, instead of ordering the studies and treatments appropriate to the patient's presentation or the known diagnosis. Notes and charts are increasingly organized to aid utilization review rather than to represent clinically useful medical histories.1,2 I find it hard to believe that any young physicians who went into medicine because they loved taking care of patients, loved science, or both would not be frustrated and anguished by the current system. . . . Until there is a fundamental reorganization of our health care system, “doctor discontent” will continue.

Elizabeth J. Murphy, M.D., D.Phil.
University of California, San Francisco, San Francisco, CA 94143

2 References

1
Kassirer JP, Angell M. Evaluation and management guidelines -- fatally flawed. N Engl J Med 1998;339:1697-1698
Full Text | Web of Science | Medline

2
Brett AS. New guidelines for coding physicians' services -- a step backward. N Engl J Med 1998;339:1705-1708
Full Text | Web of Science | Medline

To the Editor:

When I saw the first sentence of your editorial, I knew the piece would be painful for me to read. I was right, of course. From my perspective, as the spouse of a physician, the impact of the current medical scene on families such as mine has been enormous. Granted, our children's education bills are paid, and because of our thrift since the early days of our marriage, we have been able to save some money. For the first time in our 40-year marriage, however, I wish my husband were no longer practicing medicine. I, who have been an integral and enthusiastic part of his commitment to medicine and people since those early postgraduate days, wish he were out of the profession. He works longer days now and comes home physically and emotionally spent. We never talk about medical matters anymore. My anguish about his situation is as acute as his. We could deal with this, as we have so many other issues, if we believed he still had some control over his professional life.

Who would have believed a generation ago that the skills of listening and thinking would no longer be considered essential in dealing with people in pain? Who would have believed that these committed physicians would not be followed by like-minded persons? Who would have believed that my spouse's judgment, honed after years not just of study but of day-to-day dealings with people and their problems, would be constantly questioned by nameless and faceless corporate minions armed with rule books, or that these same anonymous people would determine what continuing education was or was not appropriate?

In lighter moments, I wonder whether we are not in the middle of some Kafka novel. Such moments are few, however. My spouse no longer has a profession; he has a job.

Ruzha Cleaveland
1000 Signal Mountain Blvd., Signal Mountain, TN 37377

To the Editor:

Doctor discontent arises from the economic system. The cost of health care in the United States has simply outstripped the willingness of private payers (employers) to fund it and has stressed the resources of public payers (taxpayers). All projections of expected costs for the next few years promise increased stress.

Having rejected a comprehensive, systematic approach to keeping the cost of health care within the limits of our ability to pay for it, we subject ourselves, in the best American tradition, to a variety of market experiments. Some harm the economic interests of physicians. Some may harm patients. Some, at least in the short run, appear to provide high-quality care at a cost lower than that of the market in general. We accept this situation instead of facing more difficult fundamental problems.

As Richard Lamm, former governor of Colorado, has eloquently noted,1 even now, we cannot afford to do everything that will benefit our patients. As the costs of usual health care and the “marginal therapies” on which Mr. Lamm focuses increase, our de facto rationing of health care benefits on the basis of wealth, social class, and education will further fail us as a cost-containment mechanism.

Physicians resist any constraints on their incomes, pointing to the compensation received by top-level executives at some HMOs and insurance companies and in other health-related fields as justification for virtually any level of physician income. The incomes of both physicians and executives must be addressed if the total costs of health care are to be understood.

Perhaps we physicians are in a state of denial as we suffer from this discontent. Like the patient with a worrisome symptom, we seek relief while avoiding the diagnostic process that might reveal an even less welcome underlying disease. Until physicians and organized medicine are willing to participate fully in the discussion about necessary and appropriate constraints on health care costs, this discontent can only remain a nagging and worrisome symptom.

Thomas J. Ruane, M.D.
200 Riverfront Dr., Detroit, MI 48226

1 References

1
Lamm RD. Marginal medicine. JAMA 1998;280:931-933
CrossRef | Web of Science | Medline

To the Editor:

It is time to stop attributing the financial and emotional woes of the medical profession to the imperfections of managed care. Let me divulge a little secret, admittedly based on observation, intuition, and experience: the days of complete autonomy for physicians are over. . . .

The fundamental question is, who will take responsibility for allocating finite health care resources in the most efficient, ethical way? The obvious answer is the physician, who provides care for patients. But let us not be so naive as to think that other stakeholders, such as the federal and state governments, managed-care companies, employers, and other payers, should not share this responsibility.

Trying to get doctors to practice cost-effectively by withholding money or giving bonuses is largely counterproductive. The use of such an approach reflects a lack of understanding of medical practice and is an expression of frustration by misguided managed-care companies. We in the managed-care industry should not abdicate our role as managers. Rather, we must continue to educate physicians and welcome their cooperative efforts to help provide high-quality, cost-effective health care. The time has come to stop beating each other over the head like bullies in a schoolyard.

Bernard J. Mansheim, M.D.
Coventry Health Care, Bethesda, MD 20817

To the Editor:

It is difficult to reconcile the dissatisfaction of physicians that you describe in your editorial with the degree of control that doctors enjoy over their professional and personal lives. As you correctly note, doctors can, and many do, work longer hours, see more patients, or both in order to maintain their incomes, which for decades have been among the very highest in the country. Inevitably, of course, this leaves less time for family and other non–income-generating activities. . . . I respectfully suggest that getting the public to “stop pretending that doctor discontent doesn't matter” is easy. Eliciting sympathy for “disgruntled, cranky doctors” is quite another matter.

Robert G. Newman, M.D., M.P.H.
Continuum Health Partners, New York, NY 10019

To the Editor:

You take editorial license to the outer limits, depicting physicians as virtually enslaved by health plans and warning darkly that “disgruntled, cranky doctors are not likely to provide outstanding medical care.” This is fear-mongering, pure and simple — an unsubtle message to patients that if your doctor should happen to be in a bad mood, it is some HMO's fault, and you are likely to receive substandard care as a result.

What's wrong with this picture? First, it profoundly insults the professionalism of physicians who take pride in providing the best possible care, regardless of whatever personal or professional challenges may at the moment be complicating their pursuit of happiness. Second, it is clearly at odds with the findings of the study by Grumbach et al. Their report, based on a survey of California physicians, can be made to show that “discontent” is rampant only by playing up the fact that just under half of those surveyed — 49 percent — described themselves as “very satisfied” with being physicians. But among the data not included in the report is the finding that another 33 percent of the physicians surveyed described themselves as “somewhat satisfied.” In other words, 82 percent — a substantial majority — were somewhat or very satisfied. Only 4 percent characterized themselves as “very dissatisfied.”

Also played down is the widespread recognition that health plans are doing useful work in promoting accountability and quality, among other things mitigating the well-documented variations in care that have resulted in some patients' receiving too little care and others too much. . . .

The Journal has provided new ammunition for critics who hope to browbeat legislators and regulators into restricting health plans to the point at which innovative management of health care coverage and services becomes impossible. Indeed, the California Medical Association wasted no time in using the November 19 issue to reinforce a lobbying assault on the California Department of Corporations. But in providing this ammunition, the Journal risks forfeiting its right to be regarded as a reliable source of objective information. And at a time when our ongoing national health care discussion desperately needs more rather than fewer dispassionate voices, that is a tragedy.

Karen Ignagni
American Association of Health Plans, Washington, DC 20036

Author/Editor Response

The authors reply:

To the Editor: Dr. Cohen correctly recognizes one of the fundamental tensions in all health care systems: the need of a community to keep overall health care expenditures at an affordable level, and the desire of individuals to receive all the appropriate care possible. However, we disagree that the solution to this problem is to make individual patients responsible for a greater share of their medical expenses. Direct payments by patients already constitute 17 percent of all health care expenditures in the United States, a greater share than that paid by patients in most other industrialized nations.1 There is broad agreement among policy analysts that the key to successful cost containment in other nations has been the establishment of national budgets and management of the overall capacity of the health care system.2 Financial incentives for physicians to limit care and greater cost sharing on the part of patients are both born of the same false policy hope that economic influences on individual behavior can substitute for broader public accountability for overall health care spending.

We appreciate Mr. Fisher's letter, which places our study in the wider context of research on incentives in other industries. Unfortunately, the managers and business consultants who persuaded health care organizations to adopt these types of incentive systems seem to have been undeterred by the unfavorable evidence accumulated from the research in other industries.

Ms. Ignagni is correct that our study found that the majority of physicians were either “very satisfied” or “satisfied” with being physicians. However, we are not nearly as comforted as Ms. Ignagni appears to be by the fact that nearly 20 percent of the physicians were dissatisfied with being physicians. Regardless of whether one feels reassured or disturbed by the finding that “only” 20 percent of physicians are dissatisfied, our study suggests that this percentage might well be smaller if health plans discontinued the types of financial incentives that contribute to physicians' distress. We also take issue with Ms. Ignagni's assertion of “the widespread recognition that health plans are doing useful work in promoting accountability and quality.” Although there are some examples of health plans (particularly the long-established, nonprofit HMOs) that have attempted to preserve an emphasis on quality and accountability to the community, most managed-care plans are beholden to commercial interests that measure success in terms of the short-term rate of return to investors rather than sustained improvements in the quality of care. Perhaps this is why a recent poll found that only one in three people had confidence in managed-care plans (a rating similar to those for the legal profession and television and radio news), whereas two in three people expressed confidence in the medical profession.3

Kevin Grumbach, M.D.
Andrew B. Bindman, M.D.
University of California, San Francisco, San Francisco, CA 94143

3 References

1
Levit KR, Lazenby HC, Braden BR. National health spending trends in 1996. Health Aff (Millwood) 1998;17:35-51
CrossRef | Web of Science | Medline

2
Marmor T, Oberlander J. Rethinking Medicare reform. Health Aff (Millwood) 1998;17:52-68
CrossRef | Web of Science | Medline

3
Johnson C. Poll ranks insurance brokers low. San Francisco Chronicle. October 1, 1997:A2.

Author/Editor Response

Dr. Kassirer replies:

There is little doubt that physicians are disgruntled with many aspects of our health care system. Even those who love their practices (and there are large numbers) complain bitterly about excessive paperwork, interference in decision making, and excessive patient loads. Managed care is only one of the causes of physicians' discontent. Nonetheless, I agree with Drs. Grumbach and Bindman that health plans, particularly those that are investor-owned, cannot blithely hide under an umbrella of accountability, quality, and innovation. They have also brought us gag rules, contracts with “no-cause” nonrenewal clauses, financial incentives to restrict patient care, withdrawals from the Medicare program, and refusals to share in the costs of medical education, research, and care of the poor.

Some writers have little sympathy for physicians' financial concerns, yet doctors must be adequately compensated for their efforts. I have yet to find a better justification than this passage written more than a century and a half ago in the predecessor of the New England Journal of Medicine 1:

When writing about doctor discontent, I tried hard not to raise the temperature of the health care debate further. I carefully selected terms to describe physicians' angst, such as “dismay” and “frustration.” Ms. Ignagni, the spokesperson for the American Association of Health Plans, chose to counter with “warning darkly,” “enslaved by health plans,” “profoundly insults,” and “browbeat legislators.” Ironically, she then calls for more dispassionate voices!

Jerome P. Kassirer, M.D.

1 References