Thursday, November 21, 2019

Incentives matter: physicians perform fewer surgeries on smokers

The move towards fixed fees, and away from fee-for-service, has given physicians an incentive to get their patients as healthy as possible before surgery, so that there are fewer complications.  Under a fixed fee system, e.g., $20,000 for a joint replacement, the surgeon makes less money if there are complications.
“A year from now, I’ll probably be at a point where I would require all my patients to stop smoking,” Spector said. “Currently, I evaluate it on a case-by-case basis. Over time, we’re going to feel comfortable being a little more stringent with our patients about these modifiable risks.” 
Edwards said he finds many patients “don’t take it well at first” when he advises them to quit smoking or lose weight. But many of them thank him later.


  1. The problem lies in the area of value based models of bundled payments for one surgery and care (before and after) to the physicians. If the physician receives a fee for service rather than a bundled payment for total inclusive care, then he / she would not mind the outcomes, infection rates, etc because they would still be paid, although the hospital would be penalized for the recurring infection rates within 30 days of the surgery.
    It makes sense to require the patient to stop smoking or at least cut down significantly before surgery due to the critical outcomes that the patient may experience, i.e., smokers tend to bleed more easily, are subjected to higher infection rates and do not recover as well as a non smoker would. Insurance companies penalize the physicians for patient outcomes which in this case, they cannot control
    Ever wonder why there is such a shortage on Endocrinologists across the country? In Staten Island, we are in need of Endo’s more than any other specialty. Reason for the shortage: patients’ outcomes are difficult to manage - so there are not many medical students looking to make a killing in the private sector that would hold an open door for them. The insurance companies are holding the specialists responsible for patient’s unhealthy lifestyles. Although there’s plenty to be said about patient education being held everywhere from hospitals to public forums which empower the patient to embark on a healthier lifestyle, however, the reliance is on patient choice.
    In the health system I work for, our bariatric surgeons refuse to perform any type of the bariatric surgeries: lap band, gastric bypass, and others on patients who do not conform to a healthy eating plan with exercise for at least 3-6 months. The relatively high outcomes for the patient who has already committed to a healthy and active lifestyle have best outcomes. This type of patient is more likely to continue their healthy lifestyle after the surgery than those who waltz in and expect to make no lifestyle changes.

    Bartlett, A. (2017) Living with Diabetes and The Empowered Patient. Health Central. Retrieved from:

  2. Incentives matter: Physicians perform fewer surgeries on smokers
    In England the National Health Services (NHS) “Vale of York Clinical Commissioning Group” is reviewing a health care policy for England that would require obese patients to lose weight before elective surgery. The policy would also require smokers to quit smoking for at least eight weeks before being cleared for non-life-threatening surgeries. The policy is controversial for a country that promises healthcare for its citizens from the “cradle to the grave.”
    Though England has national clinical guidelines and a Constitution that protects the rights of patients, doctors agree that treating severely obese and smoking patients is costly to taxpayers and risky for the patients. Some studies show that patients who lose weight and quit smoking before having surgery have better postoperative recovery outcomes. In many of the cases in England, patients would have to wait for up to a year before physicians will perform surgery such as a knee or hip replacement. The decision to perform surgery on obese individuals is based on that individual’s body mass index (BMI). If the BMI is higher than 40 the patient is classified as severely obese. The Royal College of Surgeons (RCS) has equated the policy with racial or religious discrimination.
    Will the same policies be introduced in the United States? One study shows that “tobacco use increases risk of wound complications and infection by creating a temporary reduction in tissue oxygenation and blood flow” for patients having spine or back surgery. The same study revealed that smoking has also been associated with worse surgical outcomes and lower return to work rates for lumbar surgery patients.
    On its face it appears that proponents of policies that deny elective surgeries to obese or smoking patients have the best interest of those patients in mind. Others, however, argue that policies that deny healthcare to specific groups are discriminatory. To adopt a policy that provides for eligibility criterion for procedures such as breast reduction, heart surgery, or spine and back surgery is unethical and sets a dangerous precedent. It is wrong to isolate a single risk factor like smoking or obesity and create a policy around those risks without taking other factors into consideration. In the United States such a policy should be scrutinized by the AMA and other medical oversight groups in order that Americans are not subjected to discriminatory policies that are not smart in the long-run. Patients who are denied surgeries are often times unemployable, need disability benefits, remain on expensive medicines and require repeated hospital stays. So not providing elective surgeries to obese or smoking patients will costs our healthcare system more to deny surgeries than to perform them on obese or smoking patients.


    Bikhchandani, J., Varma, S.K., Henderson, H.P., “Is it Justified to refuse breast reduction to smokers?” Retrieved 2/26/17 from:

    Garloch, Karen, “Doctors are refusing to operate on smokers. Here’s why the trend will grow”. Retrieved 2/26/17 from:

    Jackson, Keith L., “The Effects of Smoking and Smoking Cessation on Spine Surgery: A Systematic Review of the Literature”. Retrieved 2/26/17 from:

  3. Fee-for-service is the traditional payment system that insurance companies have been using to pay physicians for services that have provided to patients. Healthcare has been on the decline for a while with agencies and insurance companies desperately seeking new ways to improve patient care and cut unnecessary costs. “Fee-for-service, the predominant physician payment scheme, has contributed to both the continuing decline in the primary care workforce and the capability to serve patients well (Berenson, 2010).” Fee-for-service can easily be abused by physicians or offices looking to make a quick buck, they can have patients return for office visits that aren't necessarily needed. Physicians realize that every time they provide a service, they will get paid for that service, also sometimes causing services to be performed that the patient might not need (.i.e. additional lab work, screenings, and follow-ups).

    Fixed fees for services creates acceptable payments for certain types of care that have been provided to a patient, creating a standard that limits the amount that physicians can charge for. This system is similar to Medicare's Diagnosis Relate Group (DRG) payment system. The DRG creates groups based upon diagnoses that encompass acceptable services and predicted payments for patients falling within those groups. Should a patient need additional days of stay or services performed, the physician must prove medical necessity, avoiding unnecessary services or payments.

    R. A. Berenson and E. C. Rich, "U.S. Approaches to Physician Payment: The Deconstruction of Primary Care," Journal of General Internal Medicine, June 2010 25(6):613–18.

  4. US healthcare costs have consistently risen at 1.5 to 2 times the rate of the Consumer Price Index (CPI). Why? Because incentives matter, and the primary incentive for physicians, hospitals and patients in the US is to deploy and consume as many available resources as possible, regardless of the impact on patients. Providers are encouraged to act this way because they are, for the most part, paid for every unit of service they administer. Patients are encouraged to demand as many services as possible because, until recently, they were shielded from the actual cost of the services delivered. Overutilization is driven by many factors such as “defensive” medicine by doctors trying to avoid lawsuits; patients’ demands; a belief among doctors and patients that newer, more expensive technology is better.
    The US Healthcare system is fractured and healthcare reform is essential. Having said that there is truly no easy answer and many factors must be considered. First, demand has to be tempered, and that’s progressively happening with now more than 20% of Americans having high-deductible health plans, which introduces a fair amount of cost sharing. Second, the supply of services has to be more balanced, and that’s the tricky part because the supply of services should never be restrained when needed, but should be when ineffective. The science about what and when services should be delivered is not always clear, and the complexity of medicine requires nuanced approaches to the management of patients, often on a case-by-case basis. Designing provider incentives that achieve that balance is extremely difficult. Ideally, incentives that are well designed should create a financially neutral environment in which doing right for the patient equates to doing well for the clinician.
    Ironically, fixed fees as noted in the article is not the most prevalent form of payment as fee for service is still king but will not be for long. Fee for service has rewarded doctors who perform more procedures. But with reimbursement rates that are continually decreasing upward of 4 to 15% annually physicians are forced to increase volume to survive. Even when the vast majority of doctors endeavor to do the 'right thing,' reality forces them to bend to the market demands/changes.
    Lifestyle has entered the incentive methodology within healthcare. In the last ten years health insurers, hospitals, facilities and providers have pro-actively attempted to promote healthy life style choices and in doing so have implemented various programs that focus on preventative care and better monitoring and maintaining disease. Yet from an incentive perspective a provider has not been enticed to actually determine whom they will treat based on potential outcomes tied to financial incentives. The consumer should be rewarded for lifestyle choices in respect to premium payments for healthcare which are costly. Health insurance companies could offer incentives to individuals that don’t smoke, are not overweight, do not have heart disease, diabetes or high blood pressure or apply a surcharge to those that do. Frankly, this is no different than how other insurance is provided in the United States. Take care insurance for instance: Drivers who haven’t had accidents and tickets are rewarded with safety discounts and drivers with accidents and tickets pay higher premiums based on driving history.
    There are many options that must be considered in respect to the delivery of healthcare and financial reimbursements and in attacking this crisis incentives in some form or another must play a vital role in healthcare but such incentives must be financially neutral in which doing right for the patient equates to doing well for the clinician.