Tuesday, April 17, 2012

When the Government Puts Prices on Patients' Heads

Recently, another predictable Trojan-horse provision of the Patient Protection and Affordable Care Act appeared that promises to pit doctor versus patient by literally placing a price on patients' heads:
Twenty-thousand physicians in four Midwest states received a glimpse into their financial future last month. Landing in their e-mail inboxes were links to reports from Medicare showing the amount their patients cost on average as well as the quality of the care they provided. The reports also showed how Medicare spending on each doctor’s patients compared with their peers in Kansas, Iowa, Missouri and Nebraska.

The “resource use” reports, which Medicare plans to eventually provide to doctors nationwide, are one of the most visible phases of the government’s effort to figure out how to enact a complex, delicate and little-noticed provision of the 2010 health-care law: paying more to doctors who provide quality care at lower cost to Medicare, and reducing payments to physicians who run up Medicare’s costs without better results.

Of course, no real assessment of physician "quality" is taking place with this scheme nor any outcome assessment.  "Quality" as it is defined in this scheme consists of only an electronic review of patient costs, doctor billing codes, and the patient characteristics of  age, gender, Medicaid eligibility, and medical conditions.   No government entity will actually observe and assess any physician in practice to determine their "value" to the system.  Instead, patients electronically determined to be "low-cost" will be heralded as favored electronic "value" benchmarks.   Even the health care law's original physician cheerleader, former Administrator of the Center for Medicare and Medicaid Services Donald Berwick, MD, was taken back:
“We do have to be cautious in this case. It could lead to levels of gaming and misunderstanding and incorrect signals to physicians that might not be best for everyone.”
Ya think?



Anonymous said...

Although you may or may not agree with an individual mandate which occupies two paragraphs of the ACA, it is the other 2700 pages which create a 'bureaucratic' solution to the rising costs of healthcare which terrifies me. This article is emblematic of the future.
Imagine a scenario where a patient you see also has cancer. The oncologist does a PET scan every 6 months which counts against the cardiologist as excessive imaging. This is what an administrative database does! It only looks at one side of the equation. Don't be surprised if it appears that you have ordered fetal ultrasounds. The bottom line is that costs MUST be cut and this approach SEEMS more fair than an across the board cut.
I strongly believe that this is much more dangerous for the future of Medicare. As physicians feel MORE estranged and victimized by the quagmire of an expanding bureaucracy (expect lots of Vegas trips), doctors will call it quits. Every doctor will essentially be labeled with their VALUE BASED MODIFIER. In three years, you will go to a medical conference and ask your colleagues what is their modifier. "I'm a 1! I hear Smithers is a .85. I never thought he practiced good medicine."

We are doomed.

Anonymous said...

I agree. In our hospital's utilization review meeting, we got a taste of this -- the poor primary care docs were being penalized for the excesses of the consultants (and I am a consultant), but the program "isn't able" to lay blame where it should lay (and after all the hospitalist/primary care is the quarter back and can control/go against the consultant's wishes, right?).

On the flip side, my area is known for having a much higher cost /medicare beneficiary than neighboring areas. It's not hard to identify that most of that cost is in home health expenses. The HH's in my area admit a patient and never let them go.....as someone who struggles to acquire medications for my patients, I would be happy to have some health care dollars redirected to the actual care of patients.

I fear that these systems will not identify true fraud.