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.

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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.

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 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?

I think most doctors can agree that quality metrics do allow for better medicine overall. But is this going to be at the expense of healthy patient-physician relationships? The doctor above questioned whether she wanted to practice the next 30 years getting annoyed with patients who make her scores go down.

 When you are the lowest in the group for quality scores, it is a stimulus to try to score higher the next quarter. (Doctors by nature are a competitive bunch.) Does this mean you discharge your poor performing patients? The patients’ backgrounds, education and socioeconomic status can all contribute to why they make the decisions they do regarding testing and treatment. Physicians have no control over this. We can talk a convincing blue streak and still not persuade a patient to have a mammogram.

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Should doctors be financially punished for this? Also, an indigent patient may be more apt to over-utilize the emergency department even after extensive education by the staff. This will ultimately cause a lower score. Does that mean doctors shouldn’t take care of indigent patients?  My answer is certainly not!

All patients are entitled to high quality healthcare. This includes patients who refuse that care. Socioeconomic status, education level and background issues should have little to do with who we care for and how we provide that care. Physicians should always offer the best they have to give and appreciate each and every patient for who they are.

When it comes to quality scoring, even if you suffer the ding, you are hopefully still making a decent living. If all doctors gave up on the noncompliant patients, that would reflect very poorly on our profession.