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    MACRA plays blame game when patients don't adhere

     

    The emphasis among commercial payers has been on providing incentives to improve adherence and not taking punitive measures, such as increasing copays for non-adherent patients. However, penalties might not be far behind. For example, the Affordable Care Act allows insurers to charge smokers higher premiums,   

     

    ‘Playing to the measures’

    By potentially penalizing physicians for poor outcomes caused by non-adherent patients, does MACRA provide an incentive for physicians to charge those patients more—or even discharge them?

    Non-payment of bills and treatment non-adherence can be appropriate reasons for terminating a doctor-patient relationship, but discharging patients solely because their non-adherence could hurt reimbursements would seem to be unethical.

    Though it is not addressed specifically in the ACP Ethics Manual, several of its sections do speak to similar issues. For example, the manual states that pay-for-performance programs “must be aligned with the goals of medical professionalism” and cites “deselection of patients and ‘playing to the measures’ rather than focusing on the patient” as dangers.

     

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    The manual also cautions that in any case of physician-patient disagreement, the doctor is obligated to explain the basis for the disagreement, educate the patient and meet the patient’s needs for comfort and reassurance.

    Oak Street Health’s Fayanju says he hopes doctors never drop non-adherent patients just to protect their metrics, but adds that “we are being asked to assume a lot of healthcare risks for our patients.” 

    The ethics manual does not address whether it would be fair to charge non-adherent patients more to offset any Medicare penalties, though it does stress that providing the appropriate care should override any financial issues.

     

    Related: Here's why physicians need to stay the course with MACRA

     

    It’s important that frustrated physicians not view non-adherent patients as obstacles or adversaries to be abandoned, says the ACP’s Nickel. “We really want to create space where this is a partnership,” she says. “You can’t have a patient walk into a visit and feel they failed because they will then continue to fail.”  

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    • Anonymous
      Wouldn't it be nice if we could all offer all those services to our patients and still stay afloat. Oak Street sounds great until you realize they've been underwritten by 3 private equity firms and just started in 2012. Will they last? The problem is, we have limited resources. I can see 40-50 people per day and help them get "fixed" (or prevent "brokenness" because they want to get fixed (or remain healthy) and are willing to follow direction. However, more than likely, my time and resources are spent in 14-20 patients per day who will never do what I ask. So those 14-20 use up all the resources and leav 30 or so without an appointment because there aren't any slots remaining. Oak stree is also going into areas where language, literacy, transportation are the issues. God Bless them! But most of my patients don't have those issues. When will "stubbornness " have an ICD-10 code? And will we get paid more for that diagnosis?
    • Anonymous
      I'm sorry but the author after many words really said nothing constructive or helpful to physicians, just beating the drum of CMS autocrats. I am not the mother of these patients and refuse to lower myself and my profession to that level. The solution to doctors suffering is to diversify like I am; if you are mainly government 3rd party payor dependent, change location and patients. Even in the worst of places such as LA, there are still patients who will pay cash on a reasonable fee. If you are fair in cost, they will come. Even Mexico has fee for service doctors. Wake up and just say no to MACRA metrics. Let the politicians and their autocrats in CMS cringe in fear of the monster we can become.
    • Anonymous
      Talk is cheap, and neither Wendy Nickel nor Amelia Coleman express anything worthy of our attention as physicians. I've been practicing clinical endocrinology for almost 35 years, so I have attempted to help patients with the most intrinsically self-management-requiring malady of all, diabetes mellitus. Do these two commentators actually imagine that we don't try to engage people in a proper and enduring self-care strategy again, again and again? It's risible and, frankly, insulting to even insinuate otherwise. These two intellects, not to mention the feckless sheep administrators at CMS, should direct their attention to the heart of the problem, the great American food industry, that which has bought and paid for our Congress. Or maybe they need to be brought up to speed about the causation of the major illnesses afflicting our citizenry in the first place? When I tell a patient that she/he should engage in an unprocessed, whole-food, high-fiber, plant-based diet, as I do each and every patient I encounter, I realize that I am fighting the windmill of an adversary whose advertising budget would make Midas blush. So, I am personally incensed when I see the sort of bloviation presented in these articles that is supposed to impress us with its prescience. It's enough to make a cat laugh! By my estimation these commentators aren't really fully aware the degree to which the deck is stacked! Only 29.1 million Americans with diabetes mellitus and rising. This is a problem that wasn't created by physicians not properly engaging with their patients. These people need a reality check. Wake up!
    • [email protected]
      MACRA benchmarks will be easy to attain --> "Fire" all non compliant patients. I am not sure that this is "GOOD HEALTH CARE" but it will make a physician's statistics look good. I am retired for the last year but my medical practice was 95% Medicaid and I rarely "fired" patients. Lots of "no call, no show" (often patients "Fired" from other medical practices) and my statistic did not look good when compared to a 100% Insurance medical practice or a "Concierge" Practice. However, many of my patients showed improvement, perhaps not as much as could be done, but an improvement for them.
    • [email protected]
      MACRA benchmarks will be easy to attain --> "Fire" all non compliant patients. I am not sure that this is "GOOD HEALTH CARE" but it will make a physician's statistics look good. I am retired for the last year but my medical practice was 95% Medicaid and I rarely "fired" patients. Lots of "no call, no show" (often patients "Fired" from other medical practices) and my statistic did not look good when compared to a 100% Insurance medical practice or a "Concierge" Practice. However, many of my patients showed improvement, perhaps not as much as could be done, but an improvement for them.
    • [email protected]
      MACRA benchmarks will be easy to attain --> "Fire" all non compliant patients. I am not sure that this is "GOOD HEALTH CARE" but it will make a physician's statistics look good. I am retired for the last year but my medical practice was 95% Medicaid and I rarely "fired" patients. Lots of "no call, no show" (often patients "Fired" from other medical practices) and my statistic did not look good when compared to a 100% Insurance medical practice or a "Concierge" Practice. However, many of my patients showed improvement, perhaps not as much as could be done, but an improvement for them.
    • Anonymous
      Non adherence is a major malpractice risk. I have spoken with many plaintiff lawyers and they do not understand and make fun of doctors continuing to see non adherent patients. They compare it to "Russian Roulette". Their recommendation is clear cut: Discharge non compliant patients! You do not want to take the risk! MACRA does nothing to eliminate this. Therefore,my suggestion in future is straight forward: after appropriate discussion and help with what we can do to improve compliance patients with ongoing non adherence will be discharged. I also agree with all above comments, well said.
    • Anonymous
      The key is partnering with the patient, says Amelia Coleman, director of practice management consulting for MBA HealthGroup, a firm with offices in New York City and Burlington, Vermont. “Those doctors are going to have to find better ways to engage with patients; they’re going to have to take a more active approach’” she says. “A patient is going to be into a care plan if they believe in that care plan and can see how it benefits them.” I am family physician with 25 years of experience who still provides full spectrum care except obstetrics - including ICU/night call, ED coverage. This person if she had an education in medicine, could not walk 24 hours in my shoes. I have no idea why physicians listen to consultants like this. They have lost touch with reality. In my opinion, most important metric that cannot be manipulated is accessibility. Physicians know that an RVU at 2am is more difficult than at noon. Administrators, consultants and payers do not seem to understand that there is a severe shortage family physicians and internists. We don't have to put up with their rules under façade of quality metrics. Instead, any thinking doctor understands that it is really a mechanism to justify their existence and limit payments to physicians. If it wasn't for my commitment to care for my hospitalized patients, I would joint the direct pay movement. This movement will provide a much needed counter balance to these central planners.
    • Anonymous
      I was thinking the same thing "she's never taken care of a patient in her entire life". I once went toe to toe with an obnoxious politician, Virg Bernero, who insisted that if doctors would just take the time to educate their patients, patients would fall in lock step with our advice and outcomes would be improved. I used to get pretty po'd at docs who would just write RX's while I turned blue trying to talk and explain TLC. I finally figured out why. While I still spend much time educating--often getting nowhere-- it makes me much slower than others who have given up-- others to whom I am compared by the number crunchers.
    • [email protected]
      There is a point at which the patient MUST accept some measure of responsibility for his actions. If there is an ability to reach a satisfactory agreement between the patient and the physician, it should be reasonable to note in the chart that the patient refused a particular recommendation without penalizing the doctor. As long as the patient has all of the facts and has had a chance to get all of his questions answered, it is still up to him to decide what care or treatments he is willing to accept. Bureaucrats who never see a patient, and perhaps are not even physicians fullfil the premise that "Nothing is impossible for the person who does NOT have to do it."
    • Anonymous
      So I go buy a new car. They tell me to change the oil every 3000 miles, I don't. They tell me to burn regular gas, I use diesel. The engine blows up. I am going to ask for a refund of my money, must be automakers fault! Why do we put up with this bullshit? If it wasn't so real it would be comically funny.
    • Anonymous
      Love the analogy!
    • UBM User
      So I have a diabetic with rising sugars come in today. He says he likes to eat chocolate every day. He eats Hersheys kisses. I told him that he could have one a day as a compromise and he was shocked he could only have one. They are about 26 calories each so I compromised with up to four a day. He said he could not survive like that. He stated that he eats about 20 kisses per day and is unwilling to compromise on this. Under MACRA, his uncontrolled sugars and poor dietary compliance are MY FAULT?!? I don't think so.
    • Anonymous
      Yep, sorry. I have the same patients. Made housecalls-- was a real eye-opener.Didn't change anything. Still didn't listen. This is the craziest system. Medicaid providers are getting docked for not providing Pap smears to patients who don't show up.
    • [email protected]
      I would say that we should cut the salaries of the administrators and the academics because their hare-brained ideas have not cut the cost of Medicare and is driving us deeper into debt. Come on you geniuses - how about some good results!!!
    • Anonymous
      I hope the author is taking note of our comments. In some of his other writings for Medical Exonomics, he's given me the impression he's pretty ignorant of the physicians' challenges. Look at who he quoted for this article!

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