Clawback provisions in medicine?

There was a great review of the non-surgical management of appendicitis by one of the senior residents yesterday during surgery grand rounds, our weekly educational conference.  She showed data from two randomized controlled trials one done in sweden and one in the US showing that non-surgical management of an infected appendix was indeed possible and efficacious 90% of the time. Despite this data, she did not suggest that we try nonsurgical management for appendicitis (she probably would have promptly been excused from the room). Instead she simply suggested that medical management be recommended in cases where patients are not good surgical candidates such as when they are elderly with heart problems and taking drugs that thin the blood and increase the bleeding risk. Despite this seemingly modest suggestion and some pretty strong evidence, several older surgeons in the room were pretty adamantly against this sort of “uncomfortable medicine”. One reason given was, well if I didn’t operate on this patient I would be really worried and have some sleepless nights wondering whether I should have operated and I still might take them to the operating room.

This made me feel that we still have a long way to go before we “change” medicine. After all, what manager (hospital administrator) would fire their productive employees (surgery is still very profitable much more so than medicine)?

One idea I thought of was the idea of having a clawback provision in medicine. Like with airplane parts manufacturers whose supplier contracts may include what is effectively a “guarantee” that if anything went wrong with the manufacturing that was attributed to a manufacturer error, the supplier could “claw back” their purchase of the engine. Perhaps if suppliers in medicine such as device suppliers, pharma companies, physicians themselves were subject to such a provision. For example, pharma companies have to guarantee that their treatment was for the proper diagnosis as enforced by audit. Would that herald more high quality diagnosis in medicine?