Rewarding

I was glad to see that I’m not the only one obsessed with the frequency with which specialists recall patients for review. A recent US study in the Annals of Family Medicine looked at over a billion (!) specialist visits and concluded “The results of our study suggest now that not all activity performed by specialists when in a specialist role may require specialized care.” The study found a high percentage of internal demand/patient recall among US specialists.

Our recall numbers caused a little consternation in December. We’re still not sure what was going on in our clinic to give a spike in recall rates. But, we’re happy to see that they’re back down in early 2009.

There’s still a marked variation in recall rates among our group, so I think there’s still a lot of juice to be wrung out of aligning practices in this area. As our recall rates drop, we’ll open up more capacity to see new referrals.

The problem I’m struggling with is how to convince docs to return responsibility for patient follow-up to the family physician. There’s actually a disincentive to reduce recall rates. Seeing fewer recall patients means you’ll see more newly referred patients. A new consultation is more challenging and time-consuming. Often, there are x-ray requisitions and surgery booking forms to complete. Discussions take longer and there will be more questions to answer. Why not just keep recall rates high and see patients who are familiar?

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Last post, I suggested that the remuneration system that I work under rewards high volumes of services, but doesn’t offer much incentive to improve/deliver/measure quality. Judging by some of the comments from readers, that struck a nerve.

The health care system is rife with examples of perverse incentives. Of particular interest to surgeons is the method of allocating operating room time. OR time is the lifeblood of a surgeon. There’s always tension between various specialty groups around how much OR time is assigned, and how that amount is calculated.

Saskatoon’s system mainly considers the length of each surgical department’s combined wait list – that is, how many patients are waiting for surgery by that specialty. Common sense would seem to dictate that more resources should flow to the area of greatest need. Hmmm...

What outcomes does this system encourage? I want to start by saying that I sincerely believe that virtually all surgeons’ first priority for a surgical scheduling system is to ensure rapid and equitable access to surgical care for all their patients. Given that as a primary motivation, what secondary motivations exist in our system? If you want your department to have more OR time, so you can use that resource to treat your patients (and earn a living), you should build a long wait list. It’s pretty hard to schedule people for surgery unless they actually have a medical problem to treat, so it’s not like surgeons can recruit candidates for surgery off the street. But, if there happened to exist a medical condition for which there were several equally effective treatments (surgery among them), there may be some bias toward recommending surgery.

Also, there’s a perverse incentive not to innovate. If a specialty group adopts a new technique that allows a procedure to be completed in less time, their wait list will drop. How will they be rewarded? Mainly with the satisfaction of a job well done, because the departments who are less innovative will maintain long wait lists, and be rewarded with more OR time. Bizarrely, this then shifts a valuable resource away from those who use it effectively, and into the hands of those who squander it!

Of course, it wouldn’t be fair to patients if we were to use OR time as a reward for innovation; that would further lengthen wait times in the conservative specialties. Some other incentive would be necessary. Surgeons like shiny things – buy them some new equipment. Rearrange the OR schedule so the most efficient groups get the prime times, i.e., not Friday afternoon. Recognize them publicly for their efforts.

Align offered rewards with desired outcomes.