This randomized trial of a brief educational intervention of internal medicine residents showed that residents who were informed about the Medicare “no pay for errors” rule tended to be less likely to choose the most appropriate clinical practice choices in response to clinical vignettes. While actual behaviors were not measured in this study, if these clinical practice choices were to be implemented in practice, they could result in patient harm through unnecessary tests, procedures, and other interventions. Most residents were aware of the new rule, but most had important misconceptions regarding the scope and content of the rule, revealing an important gap in resident competence in systems-based practice.
There is a growing trend in the United States for insurers to use incentives and disincentives in an attempt to lower costs and increase quality of care9
. One result of this movement is that clinicians now frequently receive brief communications seeking to modify their documentation and billing practices. It is critical for practicing physicians to be aware of these new regulations, as well as to appropriately respond to the steady stream of information, which is often limited and may well be misleading, meant to influence their clinical practices.
It has long been recognized that societal systemic “purposive” changes can result in unintended consequences10
. This phenomenon has been described in other large health systems changes, such as the implementation of the “time to antibiotics for pneumonia” performance measure, which may result in the inappropriate early use of antibiotics in an attempt to excel on a performance measure11–13
. Similarly, the physician response to the new “no pay for errors” rules could have major consequences, both intended and unintended14,15
. Our study supports concerns that giving clinicians information regarding “no pay for errors” and other reimbursement rules may lead to unintended consequences with the potential to harm patient care unless such education balances individual patient needs with a more systems and reimbursement-based emphasis.
These findings have implications for both graduate medical education and for the care of hospitalized patients in general. Most importantly, in the face of financial incentives and disincentives meant to influence their behavior, physicians must continue to make patient-centered, evidence-based clinical decisions. Our study demonstrates how physicians may infer that they are expected to perform certain actions simply as a result of being informed about a new rule. Although physician professionalism should act as a countervailing force when inevitable tensions between reimbursement and patients’ best interests arise, history tells us that reimbursement-centered decisions sometimes prevail16,17
. Therefore, when providing information to clinicians about changes in payment policies, the underlying goal should be emphasized: increased patient safety and quality of care, not necessarily increased reimbursement.
This study has several limitations. Most importantly, since clinical vignettes variably predict true clinical behavior18–21
, it is not possible to generalize these results to actual clinical practices. Based on this study, we are unable to determine whether residents changed their actual behaviors as a result of being informed of new reimbursement rules, and if so, whether this had a deleterious effect on patients. Secondly, the clinical vignettes were reviewed by experts in medical education, outcomes research, and quality improvement and were felt to have strong content validity, however, they did not undergo external validation. Finally, this study was performed with internal medicine residents at a single university-based training program. Therefore, these results may not be applicable to practicing clinicians or to training programs in community-based hospitals.
“No pay for errors” rules and similar incentives meant to lower costs and improve quality and safety are here to stay. Our data support concerns that these rules can result in unintended consequences. Therefore, education in systems-based practice should teach trainees about these and other reimbursement rules, while strongly emphasizing the need to follow evidence-based medicine and a patient-centered approach. Further clinical research will be needed to determine if physician practices actually change after the implementation of “No pay for errors” rules, and whether these changes positively or negatively impact the care of patients.