Despite the fact that there is little or no evidence showing cost savings or improved patient outcomes with various value based quality programs and pay-for-performance schemes, CMS and many insurers seem dedicated to expanding these programs and the endless number of acronyms used to describe them.
Many primary care physicians cite such programs and the administrative burden that they impose as a leading cause of burnout and job dissatisfaction. The specifics behind this include tedious data entry, unfair, unrealistic or uncertain performance measures.
Even though it seems obvious that holding someone responsible for things over which they have no control is wrong, these programs are almost entirely predicated on just that. And even though it seems clear that requiring physicians to spend a large percentage of their time doing tedious data entry is counterproductive, wastes patient care time, diminishes access to care and leads to burnout, that is yet another hallmark of such programs.
As such programs become increasingly ungainly and transition from pay-for performance to punishment-for-compliance-failure it seems the time is right for a primary care bill of rights. I think it should look something like this:
- It is not and will never be the duty of a physician to force, coerce, intimidate, enforce, order or command a patient into compliance with recommended medical practices, preventive care, medications or procedures. Any payment model or compulsion for physicians to assume such a role is unethical.
- In many if not most circumstances, primary care outcomes depend on patient compliance. It is unethical and unreasonable to hold physicians fully accountable for outcomes that are primarily dependent on the patient.
- Inasmuch as the two statements above are true and reasonable, no quality metric or credit for such metric shall ever be based on any measure that is primarily dependent on patient compliance.
- Likewise, it is also unreasonable and unethical to hold a physician accountable for outcomes or metrics for which another physician is responsible. In other words, if the patient of an internist sees an endocrinologist for the management of diabetes, the internist cannot be held responsible for any metric, quality measure or outcome related to the patient’s diabetes.
- Data collection and tabulation of quality metrics will be the full responsibility of the collecting agency. No physician will be required to document such metrics solely in the format demanded by the collecting agency. As long as documentation of those metrics has been entered into the patient’s chart in any form of widely acceptable medical record, including written, dictated and transcribed notes, they will be acceptable. It will be the responsibility of the collecting agency to gather and format that data in whichever format they prefer.
- No physician will be held accountable for meeting quality care standards based on fluid, debated or unclear guidelines. More research into chronic disease management and prevention indicate that care and screening should be tailored to individual patient needs. No concrete metrics in these cases is acceptable.
- The idea that quality is more important than volume drives many quality programs. It must be acknowledged that this is a false dichotomy since it is patently and intuitively true that volume also equates to access to care. It must be understood and acknowledged that without access to care, quality of care is meaningless.
Physicians must embrace these simple, common sense concepts and use them to inform employers, patients,payers and the government how cumbersome, unfair and ineffective such programs have become.
George T. Barron, MD
Rock Hill, S.C.