Financial incentives for doctors
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7452.1328 (Published 03 June 2004) Cite this as: BMJ 2004;328:1328
All rapid responses
Sir:
Rodwin (1) and Lambert et al (2) have discussed the pros and cons of
financial incentives and distinction awards for doctors and consultants. I
strongly support the concept of financial incentives and distinction
awards for doctors. Those doctors who excell in delivering the best health
care services to the health consumers, do appropriate research at practice
level and take active participation in education and training should be
given financial benefits. The criteria for evaluation of doctors for
financial incentives must include these three interrelated components,
i.e., education, clinical services and research.
On the contrary, there should be financial disincentives for those
doctors who fail to meet the yet to develop criteria for excellent
services, education and research. Otherwise dualism will prevail, i.e.,
one group of doctors will say let them work all because they are
benefiting from financial incentives and distinction awards. This self-
driven philosophy of not engaging in competitive work will harm the
patients and award winning doctors who will bear the overall educational,
research and clinical responsibilities.
Finally, award committees must see that distinction awards and
financial incentives and disincentives for doctors should not be decided
on the basis of ethinicity and sex as found in this study (2).
References:
1. Marc A Rodwin. Financial incentives for doctors
BMJ 2004; 328: 1328-1329.
2. Trevor W Lambert, Michael J Goldacre, Elizabeth Vallance, and
Netar Mallick. Characteristics of consultants who hold distinction awards
in England and Wales: database analysis with particular reference to sex
and ethnicity.
BMJ 2004 328: 1347-0.
Competing interests:
None declared
Competing interests: No competing interests
With financial incentives one has to put safeguards in place to
prevent the noblest profession from becoming the oldest.
Selwyn D'Costa
Competing interests:
None declared
Competing interests: No competing interests
EDITOR-
I feel this is the most important editorial ever printed.This is
because it deals with the core issues of doctor patient
relationship,society,big money and ethics.
However,it will not be appreciated by the majority of doctors since
what they want is money,money and more money.They do not really care about
their patients.If it were not for litigation by patients,patient care
would have deteriorated to an all time low.But smart doctors still can
manage to keep their records neat and orderly,preventing legal action and
at the same time,cheating patients.
Incidentally,Shaw's statement also reflects on the creation of false
data base in evidence based medicine.'Publish or perish'is certainly not a
good idea for EBM since the pressure to publish is so great that a whole
lot of 'spin'or manufactured data is generated.
However,doctors are not from outer space.They are the product of
Society.Unless there is a spiritual and ethical revolution or reawakening
the present state of affairs are not going to change.This effectively
means that the editorial will remain a lament, and nothing else.
Yours sincerely,
Jaiganesh.K.V.
Competing interests:
None declared
Competing interests: No competing interests
The creation of the NHS in the UK never eliminated the conflicts.
Some doctors just became cleverer in identifying new ways of benefitting
themselves and continue to be creative. The creation of completely
separate private and public sectors in other countries, both developed and
developing never solved the problem either. This challenge is global and
there does not appear to be a simple solution for it.
Present methods used include:
1. Using rank in the NHS and affliation to a private practice to
subvert Trust policies in the use of drug protocols. I have worked in at
least one Trust where a Clinical Director imposed an antiquated
chemotherapy regime on NHS patients whilst practising 'state of the art'
care in the private hospital despite clear published multidisciplinary
team guidelines. Some thought for the Commission on Health Improvement
(CHI) in plugging this!
2. The creation of long waiting lists. Well known common and even
accepted practice in some places and plenty of challenges for
administrators - remember they could real or manufactured. What amazes me
is that people could tolerate it!
3. Peer pressure on the use of an unpublished (and thus non peer
reviewed) clinical trial result (whether positive or negative) when there
is a private practice component involved. For example, those of you in the
CHI might wish to consider asking how many hospitals in the UK used the
results of the MRC OEO2 Study in routine off-trial practice whilst
awaiting its publication (lapse of nearly 4 years between trial closure
and publication)
4. "Overservicing" or distorting the true intent of a clinical
request in Radiological practice.
5. Surgical and screening procedures abound: despite lack of good
quality evidence, some operate mostly on Level IV-land - because they
think it saves lives or leads to marked benefits.
6. Part or major ownership in private clinics, laboratories or
hospitals. Of course, if you go to one of these places and "get the best
care" you will be given the full house, including the 200 point screening
tests. One modern way is to own these through a nominee, at best not even
a relative!
7. The age old practice of dichotomy (fee splitting) is still alive
and kicking in many lands.
The essential question might be how we actually choose our medical
students and groom them to be "good ethical doctors" or have the bright
rewards of the material world blinded some of us on the way? Or, is it
that countries do not reward their doctors sufficiently for their level of
training and experience? Or, is it the ever present sin of human greed?
Competing interests:
I come from a medical family, some of whom have shares in private hospitals in Asia, but, I am a full time public servant
Competing interests: No competing interests
Ethical Problems related to the new GP contract
Rodwin writes an excellent article about the impact of
financial incentives on medical decision making. He is however
wrong to suggest that the NHS '...eliminates the need for
practitioners to perform excessive medical procedures to achieve economic
security...'(1) Since April of this year general practitioners in
the UK receive payments for so called 'quality indicators'.
These include treatments which are only marginally beneficial for
the individual patient ( statin therapy for large patient groups
<2>) or are known to have at least as many serious
side effects to the patient than benefits ( HbA1c below 7.0
for more than 50% of the patient group <3>).
I asked the GMC ( 'Protecting Patients, Guiding Doctors') for
advice in this matter but I understand from their responses that
they are neither interested in NHS policies nor in evidence
based medicine.
As a GP here in the UK I am in a dilemma since
attainment of ' Quality indicators' is defined as good clinical
practice as well as attracting income. I therefore have to
adhaere to those targets and accordingly will receive financial
inducements although I know that a substantial number of
patients would not choose their treatment when informed about the
absolute benefit those treatments confer (4).
I do not know if and when this anomaly will be tested
in the medicolegal field. In any case, the doctor patient
relationship will suffer once our patients see behind the smoke
screen.
References
1) Rodwin M. Financial incentives for doctors.BMJ 2004;328:1328-
1329 (5 June)
2) Heart Protection Study Collaborative Group. MRC/BHF heart
protection study of cholesterol lowering with simvastatin in 20,536 high
risk individuals: a randomised placebo controlled trial. Lancet 2002;360:
7-22.[CrossRef][ISI][Medline]
3) McCormack J, Greenhalgh T. Seeing what you want to see in
randomised controlled trials: versions and perversions of UKPDS data. BMJ
2000;320: 1720-3.[Free Full Text]
4) Misselbrook D, Armstrong D. Patients' Responses To Risk
Information About The Benefits Of Treating Hypertension
Brit J Gen Pract 2001; 51: 276-279
Competing interests:
interested in EBM
Competing interests: No competing interests