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    Do quality measures disillusion young doctors?

    Editor's Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Lori E. Rousche, MD, a family physician in Souderton, Pennsylvania. She is also the hospice medical director for Grand View Health in Sellersville, Pennsylvania. The views expressed in these blogs are those of their respective contributors and do not represent the views of Medical Economics or UBM Medica.

    Lori Rousche MDRecently at a full meeting of our seven-office, 25 physician practice, the topic of incentivizing doctors through quality medicine was discussed. The days of straight fee-for-service payments are gone. Many of us get separate bonus payments for quality medicine.

     

    In case you missed it: 6 things doctors need to know about MACRA final rule

     

    Whether you participate in CPC+ (Comprehensive Primary Care Plus), MSSP (Medicare Shared Savings Program), or separate arrangements with private insurers, you are probably receiving a portion of your money as a bonus for quality. The quality payment is based on a score that can encompass how well you hit your quality metrics, proper coding (including Hierarchical Condition Categories-HCC codes), documentation and citizenship.

    One of our newest doctors was questioning the value of paying doctors for quality. She expressed concerns that this was making it difficult for her to practice medicine without second guessing her motives. If patients are going to hurt the practice’s financial bottom line by causing adverse scores, are they patients we want to continue to serve?

    As an example, say you have a new 55-year-old patient who comes in to the practice for a routine physical. As the interview goes forward, you appreciate what a nice man this is. You both have black labs and two sons. You are bonding well in the first few minutes. However, as you get into the nitty gritty of his health issues, he promptly refuses all screening tests and doesn’t want any more medications. The patient does not want a colonoscopy. Nor is he willing to treat his high cholesterol with an LDL of 211. And although he understands the importance of good control of his diabetes to avoid long term complications, he is adamant that his hemoglobin a1c of 9.1% is fine.

     

    Related: Better quality will equal better pay for physicians

     

     He will not agree to any more diabetes medicines, because he is sure they will cause him to gain weight. Our young colleague at this point is no longer appreciating this nice man. She is rolling her eyes on the inside and thinking, “Great, now I’m going to get dinged.” By this, of course, she means she will score poorly on her quality metrics and lose out on the shared bonus money. This has happened to all of us at one time or another. Patients we respect and care for causing us to lose money by not meeting the insurance company’s quality goals.

    Next: Should doctors be financially punished for this?

    3 Comments

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    • papapete57@------.com
      We, as physicians, provide a service: medical care. We provide that care and make recommendations for our patients. If they choose not to accept those recommendations, such as colonoscopies or medications or to exercise and lose weight when needed, we should not be penalized for those patient choices. In my opinion, medicine lost its way when we accepted payment based on codes and scores, and not on the time spent taking care of our patients, no matter the outcome.
    • Anonymous
      Dr. Rousche, Thanks for your article. I find it timely and important. I do agree with the previous commenter. What I see in this interaction is physicians accepting a lesser payment for their services. We all know that patients like the one in your post make decisions that don't satisfy 'best practice' requirements. Why should you accept less money to care for them? The argument that we still are compensated well is a canard in this scenario. I would argue that we are starting to participate in a system in which we die a death due to a thousand small bites. You don't notice or feel the first one (or 500), but by the time you realize the problem it's too late to reverse the changes. All the sudden we are merely moderately well paid labor, not the masters of our own destiny. I hope that doesn't come across as too cynical. I think it is easy for large businesses and the governmental payer programs to take advantage of doctors. In the end, we just want a chance to help and positively influence our patients. Ironically your younger colleague has a much better chance of doing that over time without the 'pay for quality' metrics that now color our decisions!
    • UBM User
      Dr. Rousche, With all due respect, this is a cop out of an excuse to end the blog post. What do you mean by "decent living"? Do you really believe that all doctors go into medicine thinking about getting dinged? Why do you passively accept this weird notion that quality can be quantified in the form of metrics? Your young associate is absolutely correct in her inference. Give her some credit please. Your big practice bosses should have the spine to tell Medicare and other insurers that this is simply an unfair and inaccurate way to pay for care. If they insist on metrics, let them eliminate scores from patients who decline standard advice, so scores actually reflect the doctor's role in outcomes. Good technology should be able to do that, if you believe in it. Otherwise, you owe it to your patients and profession to pull out of all such payment arrangements. Just saying...

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