Bill Gates has 'one weird trick' to fix US COVID testing
Can it work in other areas of healthcare
We’re almost 6 months into the pandemic and our COVID testing is still unacceptably bad. Although testing remains limited in terms of accuracy, the real issue is that the tests take a really long time to come back.
Test results are generally so delayed as to be close to useless in clinical care and to guide patients at home about whether or not they are infectious.
Bill Gates gave an interview to Wired Magazine where he discusses this testing problem. He makes a ton of really important points and I would recommend reading the interview in its entirety.
On testing, he has an idea to fix the time delay in COVID testing:
The majority of all US tests are completely garbage, wasted. If you don’t care how late the date is and you reimburse at the same level, of course they’re going to take every customer. Because they are making ridiculous money, and it’s mostly rich people that are getting access to that. You have to have the reimbursement system pay a little bit extra for 24 hours, pay the normal fee for 48 hours, and pay nothing [if it isn’t done by then]. And they will fix it overnight.
He’s totally right.
The majority incentives in the American health care system has never cared about efficiency or effectiveness. Or even not screwing up, for that matter.
Paying for performance is a good idea - in theory - that might actually help with fixing our delays in testing.
But any policy changes in healthcare need to be considered from the perspective of unintended consequences. What could go wrong? Why don’t we applying this idea to the rest of healthcare? Could implementing financial incentives fix our broken system?
Paying for performance in healthcare is tricky
On a superficial level, of course we should be paying for performance. But when you get into the details, things start to get tricky.
There are a handful of major problems with trying to create incentives for better patient outcomes (an admittedly incomplete list):
Financial incentives make people game the system
Measuring performance is really hard
The sickest patients can end up not receiving care that they might “need”
All policy discussions need to take place in the realm of downstream consequences. In any complex ecosystem, even minor changes to incentive structures can have massive ripply effects. If you don’t think about the unintended effects, your policy changes may fail to make things better, or even make them worse.
Take the Gates example of paying for quick testing
If you only pay for tests that are done within 48 hours, will companies take shortcuts in their testing protocols that lead to slightly less accurate results?
Will accuracy be compromised to get things done in 24 hours for a bonus?
And how do you judge the accuracy of the quicker testing?
After all, we don’t want to just pay for speed, we also care about accuracy.
The major issue with payment for performance in healthcare is a corollary to the challenge of adding technology - being wrong can have major health consequences.
Let’s look at some other examples of problems with healthcare incentive structure
Let’s take a quick look at the problems I mentioned above:
Financial incentives lead to gaming the system
Take the example of electronic healthcare records (EHRs). The government mandates - under financial penalty - that EHRs incorporate something called “meaningful use,” which means that they fit a handful of metrics to evaluate whether their use is meaningful. The result is bloated electronic systems that inhibit patient care as much as they help it.
Measuring performance is really hard
Think about placing a stent in a patient with a blocked coronary artery. How are you measuring the effectiveness of this? Is it preventing a heart attack? Is it preventing a heart attack within 30 days? Is it relieving pain? Is it reducing the number of medications that they take? Is it preventing hospitalization? Is it survival to discharge? What if the values of the reimbursement metric aren’t aligned to the patients value?
The sickest patients can end up not receiving care that they might “need”
When you reimburse based on survival, patients will be cherry picked based on likelihood to survive. Sicker patients have potential to derive a greater benefit from therapeutics but are also more likely to die. If payments are based on survival rates, you might be a bit less inclined to take a high risk patient to surgery.
This stuff is complicated!
I am certainly NOT suggesting that paying for performance in healthcare is pointless and that we shouldn’t be doing it.
What I’m saying is that we need to be mindful of the consequences of the incentives that we create. The idea that Gates described to fix testing actually sounds good!
But thoughtful mandates are not easy to come up with!
Idea implementation needs to be mindful of how a complex system might take well-intentioned ideas and bastardize them into something that makes everyone worse off.
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