Evidence from Thee, but Not from Me

Via the Healthcare Economist and Health Care Renewal, I was led to a recent editorial in the BMJ (formerly the British Medical Journal):

[In the National Health Service,] something important is quietly dying. I don’t think it is too fanciful to call it the spirit of medical professionalism. And we, the medical profession, are watching it die….

[F]ar from being privatised, medicine in England has become ever more a creature of the state….

[A]lthough medicine has embraced the need for evidence-based medicine, policy making remains largely an evidence-free zone.

Politicians consolidating and centralizing power…government sucking the soul out of a profession…ho-hum. It was the last line that really caught my attention. 

I’ve noticed the same tendency on this side of the pond. For example, policymakers such as Sen. Chuck Grassley, Rep. Nancy Johnson, and the Institute of Medicine want Medicare to cook up “pay-for-performance” financial incentives that reward providers who deliver what the evidence suggests is “quality” care. You know, pay them to follow the evidence. As Forrest Gump might say, that’s a fine idea. The only problem is, private insurers have been trying that idea for 10 years, and there’s scant evidence to show that it actually works. 

Personally, I think “P4P” has the potential to do a lot of good. But in a recent paper on the topic, I had to note the irony:

The P4P movement proceeds from two premises: first, that clinicians tend to underuse evidence from randomized clinical trials and, second, that financial incentives can increase such use and improve the quality of care. Yet whatever enthusiasm exists for P4P is not derived from the type of evidence of effectiveness that P4P enthusiasts believe should guide clinical practice. Third-party financial incentives remain an unproven tool for improving health care quality at all, let alone in a cost-effective manner.