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WHEN we arepatients, wewant our doctorsto make

ByBy PAM E L A HART Z BANDPAM E L A HART Z BAND an dan d JE ROM E GROOP M ANJE ROM E G ROOP M AN NOV. 18, 2014

COMMENTThe Opinion Pages | OP-ED CONTRIBUTORS

How Medical Care Is Being Corrupted

Alex Merto

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recommendations that are in our best interests as individuals. Asphysicians, we strive to do the same for our patients.

But financial forces largely hidden from the public are beginning to

corrupt care and undermine the bond of trust between doctors andpatients. Insurers, hospital networks and regulatory groups have put inplace both rewards and punishments that can powerfully influence yourdoctors decisions.

Contracts for medical care that incorporate pay for performance directphysicians to meet strict metrics for testing and treatment. These metricsare population-based and generic, and do not take into account theindividual characteristics and preferences of the patient or differing

expert opinions on optimal practice.For example, doctors are rewarded for keeping their patientscholesterol and blood pressure below certain target levels. For somepatients, this is good medicine, but for others the benefits may not

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outweigh the risks. Treatment with drugs such as statins can causesignificant side effects, including muscle pain and increased risk ofdiabetes. Blood-pressure therapy to meet an imposed target may lead toincreased falls and fractures in older patients.

Physicians who meet their designated targets are not only rewardedwith a bonus from the insurer but are also given high ratings on insurer

websites. Physicians who deviate from such metrics are financiallypenalized through lower payments and are publicly shamed, listed oninsurer websites in a lower tier. Further, their patients may be required topay higher co-payments.

These measures are clearly designed to coerce physicians to complywith the metrics. Thus doctors may feel pressured to withhold treatmentthat they feel is required or feel forced to recommend treatment whoserisks may outweigh benefits.

It is not just treatment targets but also the particular medications to beused that are now often dictated by insurers. Commonly this is done byassigning a larger co-payment to certain drugs, a negative incentive forpatients to choose higher-cost medications. But now some insurers areoffering a positive financial incentive directly to physicians to usespecific medications. For example, WellPoint, one of the largest privatepayers for health care, recently outlined designated treatment pathwaysfor cancer and announced that it would pay physicians an incentive of$350 per month per patient treated on the designated pathway.

This has raised concern in the oncology community because there isconsiderable debate among experts about what is optimal. Dr. MargaretA. Tempero of the National Comprehensive Cancer Network observedthat every day oncologists saw patients for whom deviation fromtreatment guidelines made sense: Will oncologists be reluctant to makethese decisions because of an adverse effects on payments? Further,some health care networks limit the ability of a patient to get a secondopinion by going outside the network. The patient is financiallypenalized with large co-payments or no coverage at all. Additionally, thephysician who refers the patient out of network risks censure from thenetwork administration.

When a patient asks Is this treatment right for me? the doctor faces apotential moral dilemma. How should he answer if the response is to hispersonal detriment? Some health policy experts suggest that there is nomoral dilemma. They argue that it is obsolete for the doctor to approacheach patient strictly as an individual; medical decisions should be made

on the basis of what is best for the population as a whole.

We fear this approach can dangerously lead to moral licensing thephysician is able to rationalize forcing or withholding treatment,regardless of clinical judgment or patient preference, as acceptable for

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M O S T E M AI L EDM O S T E M AI L ED

the good of the population.

Medicine has been appropriately criticized for its past paternalism,where doctors imposed their views on the patient. In recent years,however, the balance of power has shifted away from the physician tothe patient, in large part because of access to clinical information on theweb.

In truth, the power belongs to the insurers and regulators that controlpayment. There is now a new paternalism, largely invisible to the public,diminishing the autonomy of both doctor and patient.

In 2010, Congress passed the Physician Payments Sunshine Act toaddress potential conflicts of interest by making physician financial tiesto pharmaceutical and device companies public on a federal website.We propose a similar public website to reveal the hidden coerciveforces that may specify treatments and limit choices through pressureson the doctor.

Medical care is not just another marketplace commodity. Physiciansshould never have an incentive to override the best interests of theirpatients.

Pamela Hartzband and Jerome Groopman are physicians on the faculty of Harvard Medical School and co-authors of Your Medical Mind: How to DecideWhat is Rig ht for You.

A version of this op -ed a ppe ars in print on November 19, 2014 , on page A25 of the New Yorked ition with the head line: How Med ical Care Is B eing Corrupte d.Order Reprints | Today's Paper | Subscribe

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