Good Intentions, Worse Outcomes: How Incentives Backfire

0:00 One of the more frustrating things for patients and doctors and nurses that they all share these days is that we introduce a policy to solve a problem, but the incentives created by that policy end up making the original problem worse or even more dangerous. So let's give an easy example that is frustrating patients to no end, A policy that decreases patient satisfaction both in scores and in real life is the fall prevention policies that many, many hospitals have just beat into their staff.

0:39 To reduce patient falls and hospital penalties. We strongly discourage patients from walking, sometimes put bed alarms on their bed if they're trying to get up to go to the bathroom. And we don't have the staff to respond to them quickly to get them up to the bathroom and certainly don't have the staff to walk them in the halls and do all things we need with physical therapy, occupational therapy, more nurses, all the things that we know are lacking in most hospitals throughout the country.

1:09 And so what happens is these patients become deconditioned, they become weak, they sit in their stool and their urine. And after they discharge, they're now weaker and at greater fall risk after they leave. I mean, we all know that keeping people in bed is one of the worst things you could do for someone's health.

1:32 I mean, just forget about the DVTs and the bed sores and all things we just see day after day. But, you know, there's even data that keeping somebody in bed, particularly elderly patients. So there's a JAMA research article that looked at 10 days of bed rest on skeletal muscle effect, and that was in 2007. That's the title of it, Effect of 10 Days of Bed Rest on Skeletal Muscle in Healthy Older Adults.

1:59 And they lost 3.3 pounds of lean body mass. Basically, they lost that much muscle, most of it occurring in their legs when you were bed bound for 10 days. Another study that is from 2008 in the Journal of Gerontology looked at the reduction in knee extension strength and stair climbing power and aerobic capacity after being bed bound for 10 days and it was very significant.

2:28 But we have this policy where we're not measuring after hospital falls, meaning we know they're going to maybe go to some care facility where there's one nurse for 20 patients and they'll fall there or they'll go home and be alone or with a family that can't watch them every minute and they'll fall at home.

2:48 But what is measured is just the hospital fall and it becomes an obsession of hospital administrators, of nurses, of everybody, to make sure that someone doesn't fall in the hospital, even if their health is at risk and gets worse, which we pretty much know is happening. And that is just one example in modern medicine, because there are dozens, if not hundreds, of these type of examples of why we are failing as a medical system.

3:22 And this is originally known as the cobra effect. And why is it called the cobra effect? Well, British colonial India in the late 1800s, the British officials in Delhi were really upset about the amount of dangerous cobras in the population in the city, so they offered a cash reward for every dead cobra, which initially worked.

3:45 But then people became smart and started breeding cobras to collect more rewards. And then when the officials discovered this, they ended that bounty program, and then the breeders released their now worthless Cobras into the street, and the result is more Cobras than before the program began. Now, let me just say...

4:08 That's actually a legendary story, but probably didn't happen. What we can learn from the story is more important than the historical evidence of the story, which is pretty weak, and it most likely is a myth. Meaning there was a time in the 1870s when British authorities did offer bounties for killing venomous snakes in India, but the concept and historical evidence that people then started breeding cobras.

4:37 It's probably something that did not happen. That being said, there were things in history that did happen that were very similar. So like in Hanoi, Vietnam in 1902, the French colonial authorities offered rewards for dead rats using their tails as the proof. So people began cutting off the tails and then releasing the live rats, allowing them to reproduce. And in that instance, rat farming was actually reported.

5:05 But if you want proof in modern medicine of us doing this, the evidence repeats itself over and over. I can give so many real life things that happened during my career, which still is going on. So there's going to be more that happens. But. Let's use the example of making ICU blood glucoses nearly normal, and that increased mortality.

5:31 The original goal, hey, prevent complications from hyperglycemia in critically ill patients. So intensive insulin therapy targeted glucoses of approximately 80 to 108. And the idea was if glucose is harmful, making it normal should improve outcomes. Unfortunately, the NICE sugar randomized trial of more than 6,000 ICU patients showed that when we did intensive control of blood sugar, the mortality rate was 27.5%.

6:05 If we weren't so obsessed about things and did conventional control, the mortality rate was 24.9%. The point being is that when we look at just one measure instead of looking at the entire patient-centered outcome, we often fail in modern medicine. And since I'm mentioning the NICE trial, I think it's also important to state that it wasn't just about mortality, meaning severe hypoglycemia was far more common in the intensive control group.

6:37 So about 7% of patients got severe hypoglycemia, whereas less than 1% of patients got it in the conventional arm. And one of the bigger problems than just these bedside things that are done in one type of place like the ICU or the hospital ward is the bigger issues that happen in policy. So, Medicare's hospital readmission reduction program that was implemented in 2012, it penalized hospitals with excessive 30-day readmissions.

7:13 What happened? Well... As we know, when there's an incentive, there are results that happen from that incentive. In this case, you're going to get people out of the hospital faster. Not necessarily a bad thing, but it is a bad thing when it increases mortality, which it did when they looked at 115,000 heart failure patients after this measure was implemented.

7:39 The mortality went up from 7.2% to 8.6% during the penalty phase. More examples. When the Joint Commission established the four-hour antibiotic standard for pneumonia, what happened? It created a pressure to treat a diagnosis before diagnosis was established. So instead of us physicians looking for all the possibilities like pneumonia and CHF and COPD exacerbation and pulmonary embolism and other things that can look very similar, we all focused on the performance measure.

8:18 And therefore, we would label patients as having pneumonia and immediately give them antibiotics to meet the measure. And it was very predictable what would happen and what was published in CHEST in 2007, that there was a lot of misdiagnosis of community-acquired pneumonia and a heck of a lot overutilization of antibiotics.

8:42 I'm not sure utilization is the right word. Just misprescribed antibiotics. There is a lot of rewarding in U.S. Modern medicine for how quickly you do something rather than how accurately you do it. And nowhere, and I mean nowhere, is that more glaring than how fast office visits have to be for complicated patients.

9:06 And really now, it's becoming how fast hospital medicine visits have to be for very, very complicated patients. And since very few of us work for ourselves, if we try and stand up against the rigid, financially consequential performance metrics that are put out there for physicians and really just about everybody in healthcare.

9:30 I've seen it over and over where those people who took a stand got fired. It is so obvious why patients are so unhappy with physicians and PAs and NPs and nurses across the system right now. It's almost a no-win situation for the patients and everybody that's trying to give good health care. And it's not just in timing of hospital visits. I'm not trying to be negative here, but we really got to do something to change this system.

10:04 I mean, if you look at just hospital-acquired infection penalties right now. We try to reduce infections by financially penalizing hospitals for preventable complications. A good idea as a goal, but why it backfires, is hospitals have an incentive to focus on how infections are classified and coded rather than really trying to prevent infections.

10:29 And while there's no limit really to these type of examples, what ends up happening is in hospitals and medical practices. We have a lot of people, particularly physicians that have seen it when the system was better. A lot of people get referred to anger management, but we don't have many referrals for stupidity management.

10:54 In fact, stupidity is often rewarded. And so we have a lot of the systems and processes that we know, I mean, these are plainly stupid ideas, and then people get mad that this is going on, patients get mad, physicians get mad, nurses get mad, and the cycle keeps repeating itself. It's not that I would excuse anger. In fact, it almost never solves anything.

11:23 But somewhere along the way, we began confusing moral conviction with anger in some circumstances. There are some times where we have reached these points where standing up for what is right is too often seen as anger rather than integrity. There are a lot of times, both in hospital medicine and in clinics, where there's really nothing left to do medically as far as treatment, as far as pills, as far as injections, and presence becomes the care.

11:57 But that doesn't exist now because we don't have time to be present. We don't have enough physical therapists because they aren't money making for a hospital to get our patients out of bed maybe more than once or twice during the entire stay, in a lot of hospitals at least. I mean, now we all have these morning rounds, which are good, and sometimes they point out important things, like someone's not on DVT prophylaxis or has a catheter that doesn't need to be in.

12:28 But let's face it, mostly it's about how do we get this patient out of the hospital. But imagine if on morning rounds we started as hospital systems as a country to make mobility several times a day the priority on that rounds. Did that patient get out of bed four or five times? I mean, is it even conceivable in our heads that that would decrease DVTs, that that would decrease the needs of catheter usage, that that would decrease muscle loss in future falls, that it would be somewhat of a natural incentive spirometry to take deeper breaths as you're walking the halls and doing some exercises?

13:14 We all know that that's beyond conceptual, that that kind of thing would really, really help. But we're stuck in this COBRA effect in healthcare, where we try to solve little individual problems, which ultimately is trying to successfully treat the spreadsheet. And as we try to solve those little individual problems, we create a committee to solve it and then end up with mandatory training modules and somehow two new problems that didn't exist.

13:46 And there's times when we just learn that what we are doing is not correct. And that's okay. That's science. I mean, medicine is full of that and that's okay. We change our way of doing things like we were using higher tidal volumes in ARDS, thinking that was helpful. It wasn't. We used to give platelets to reverse aspirin-associated brain bleeding.

14:10 Bad idea, as the PATCH trial found out. Giving those platelets doubled the odds of death. I mean, we used to suppress PVCs after myocardial infarction. Antirhythmics were given, and the CAS trial decided, eh-eh, you don't want to be doing that, it'll increase overall mortality. I mean, we used to give oxygen to every MI patient, but that was of no benefit.

14:36 And we can go on and on, right? Sepsis, fluid boluses, all kinds of things where, oh my gosh, the Zygris trials with sepsis. I mean, how many billions do we waste on that drug? And the point is, when we realize that we're doing something wrong, it's a really good idea to reverse course. But it doesn't feel like that's happening as much these days, particularly, with medical policy and funding and all kinds of incentives that may have some good intentions, but a lot of unintended consequences.

15:15 And what I'm even more worried about is we keep finding things like private equity. There's now substantial published evidence that private equity ownership in healthcare is associated with worse outcomes for patients and significant disruption for physicians. You know, literally has found increased hospital-acquired complications, including infections, but also falls, and higher healthcare costs, and increased physician turnover when a private equity acquisition happens.

15:51 But we don't do anything to make a policy to stop that. Are we really living in a culture where people are increasingly afraid to speak up, challenge authority, or question the status quo? Because somewhere along the way, we've allowed the fear of doing what's right to become greater than the fear of doing what's wrong.

16:15 And it's not just in healthcare. This is happening in a lot of parts of society throughout the world where we live in a time where fear is replacing courage. We see things that are wrong. We recognize policies that are harmful. And yet too often we remain silent because speaking up probably will cost us something.

16:37 And I'm not talking about being a bomb thrower or just complaining to complain. There is a lot of that. And we see that in health care plenty. I'm just worried we're going to get so far down the path that we may already be there. Where we're more concerned about the consequences of our silence than the consequences of speaking up. I think it's something we just really need to think about as a tribe, as a health care tribe.

17:05 So let's stop complaining and be part of the solution, says the guy who spent this episode complaining. All right, y'all, I will catch you on the next round.