Today I got a fax that made my jaw drop and my heart sink.
A pharmacy benefits manager, the part-insurance-and-part-mail-order-pharmacy for a few of my Medicare patients, was contacting me to point out that there was a new incentive for me to consider:
For each of the diabetic patients listed on the second page of the fax, I would be paid $100 if I prescribed an ACE inhibitor or an ARB (angiotensin receptor blocker) by the end of next month.
Only one patient was listed, an extremely well controlled diabetic single gentleman in his late 70’s, Gerald Spike. Gerald has lowish blood pressure, has fallen twice in the last year, and his MCV (the size of his red blood cells) is above the normal limit. His B-12 and folic acid levels are normal, and the next likeliest explanation for this is alcohol consumption. Gerald swears he only has one glass of wine every night with his dinner.
Gerald is not a good candidate for an ACE or an ARB. I personally am not convinced that any well controlled diabetic with normal kidney function, normal urine microalbumen and normal blood pressure should be on one of those medications, especially at Gerald’s age, but that is a different story. He could ill afford to have his blood pressure lowered even a little.
Offering a cash incentive for doing something that could harm a patient, and which in one or several ways profits the pharmacy benefits manager, be it in their quality metrics, moneys paid to them by the main insurer, or copays from patients – is unethical. Call it an incentive if you wish; bribe or kickback are more accurate words for this.
If I had thought Gerald would have benefitted from an ACE or an ARB, I would have prescribed one already.
I still remember Hippocrates’ words:
“I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.”
A Country Doctor Writes: 
A voice crying out in the wilderness. Keep speaking out. “Bribe”, “Kickback” perhaps a little too kind. Sad commentary on the Profession of Medicine.
Perhaps less dramatic, but much more common: institutions that have financial incentives/penalties in place to ‘incentivize’ clinicians into channelling their patients into decision making that makes the institution look good on paper and qualify for better reimbursement. No one would consider it ethical to have kickbacks based on which brand of total knee was used, but clinicians routinely accept as legitimate incentives (bribery or blackmail?) to convince their patients to have mammograms every 2 years starting at 40, or pneumococcal vaccine, or an A1c under 7, or to be screened for fall risk or depression (without a treatment plan).