Cancer Surgeons and Health System Innovation: Incentivizing Change
JNCI J Natl Cancer Inst (
editorial Cancer Surgeons and Health System Innovation: Incentivizing Change
Mark S. Litwin
Hung-Jui Tan
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Affiliations of authors: Department of Urology, David Geffen School of Medicine (MSL, HJT), and Department of Health Policy & Management, Fielding School of
Public Health, University of California, Los Angeles (MSL).
Far removed from ivory towers and beltway pantheons, cancer dwarfed by the additional $1000 paid out by Medicare—arg-u
doctors—pecuniarily intoxicated from historically profitable ably a profitable return for simply deploying a small electrode
goods and services—today face a starkly sobering, new ec-o or biopsy forceps in the office. The consequent inference is that
nomic truth: Revenue must balance cost to keep a practice or urologists responded to the reimbursement change by optim-iz
health system afloat. In training, physicians dedicate years in ing revenue rather than value.
preparation for careers set in clinics and operating rooms, only In many respects, this finding should come at no su-r
to realize that much of their real-world impact is pinioned by prise. The literature is replete with examples of physicians
decisions made in the business office. There, patient charts bu-t responding predictably to financial incentives. Increased u-ti
tress profit-and-loss statements; physicians wade through c-od lization has been linked to physician ownership of in-office
ing updates, peer-to-peer pre-authorizations, and costly new imaging, laboratories, and ambulatory surgery center3s).(In
processes, such as electronic health records, patient registries, prostate cancer, inappropriate administration of androgen
quality reporting1(), just to maintain viability in the 2st1century. deprivation therapy ran rampant until reimbursements -lev
In light of such considerations, physician behavior remains els were slashed, and the most egregious offenses resulted
highly susceptible to financial incentives, especially in a (w-an in jail time (4). In a recent study, nearly one-fourth of s u-r
ing) fee-for-service environment where productivity equals pa-y veyed medical oncologists acknowledged that administ-er
ment. In this month’s issue of the Journal, O’Neil and colleagues ing more chemotherapy or growth factor would supplement
from Vanderbilt2() report on the effect of Medicare reimburs-e their income, further supporting the notion that financial
ment changes, promulgated in 2005, on the performance of incentives, in one form or another, touch nearly every facet
minor outpatient cystoscopic procedures for patients with b-lad of cancer care (5).
der cancer. Designed to shift these services from higher-cost Given the power of financial incentives, how do we overcome
facilities to lower-cost settings, the reimbursement changes the “more for more” culture of clinical medicine? At a policy
had the opposite effect. The authors found that office utilization level, new payment and delivery models, such as accountable
soared to 644%, without a corresponding decrease in procedures care organizations, medical homes, bundled payments, and
performed in hospitals or surgery centers. In effect, patients value-based purchasing, hold more than quixotic promise.
endured more procedures per diagnosis, a practice abrogated By assigning financial risk or linking pay with performance,
only by a subsequent reduction in reimbursements for office- these innovations aim to recalibrate the compensation st-ruc
based cystoscopic procedures. ture so that doctors are rewarded for value (ie, quality per cost)
The authors offer two plausible explanations. Physicians rather than volume. Despite heavy investment in such stra-te
opted either to biopsy/fulgurate lesions they would otherwise gies, data supporting their feasibility or effectiveness remain
have managed expectantly or instead to perform both an office- sparse. In a pilot program involving medical oncology pr-ac
based procedure and a second, more definitive operation in a tices, UnitedHealthcare found that episode-based payments
hospital or surgery center. In either scenario, the case for utility coupled with performance data–generated cost savings among
can be argued. Benign or indolent conditions could be identified, patients treated for colon, breast, or lung cancer; parad-oxi
thus negating the need for future cystoscopies or more involved cally, this occurred despite higher utilization of chemotherapy
procedures. Alternatively, anxious patients would be mo-lli (6). Integrated delivery systems—the forerunner to accountable
fied by a preliminary diagnosis, even though they would need care organizations—appear to result in lower readmission rates
more definitive treatment. However, these potential benefits are for colectomy, a common cancer surgery, while maintaining
overall costs and morbidity rates similar to those in noni-nte cancer care delivery systems will be critical if we are to bend the
grated hospitals7(). medical cost curve down. Urologi (...truncated)