In Britain, a program was begun over a decade ago that would pay general practitioners up to 25 percent of their income in bonuses if they met certain benchmarks in the management of chronic diseases. The program made no difference at all in physician practice or patient outcomes, and this was with a much larger financial incentive than most programs in the United States offer.
Even refusing to pay for bad outcomes doesn’t appear to work as well as you might think. A 2012 study published in The New England Journal of Medicine looked at how the 2008 Medicare policy to refuse to pay for certain hospital-acquired conditions affected the rates of such infections. Those who devised the policy imagined that it would lead hospitals to improve their care of patients to prevent these infections. That didn’t happen. The policy had almost no measurable effect.
No doubt about it: Changing behavior is hard — especially when there is a significant amount of uncertainty about outcomes. But we’ve made it worse in health care. When the doctor is accountable to the National Health Service or an insurer chosen by his patient’s employer, it is demoralizing and difficult for the patient and doctor to give signals to each other about quality and value.