Are We Selling Our Professional Autonomy for a 0.5% Medicare Rebate Check? – by Robert Nelson, MD

I have to get something off my chest.

7fd1a-6a00e5520572bb8834017d3e731553970c-piI just received the latest of many email updates on “quality reporting initiatives” from the leadership of the Urgent Care where I moonlight.  It seems they have made the decision to get on board with “pay for performance” by enrolling in CMS sponsored PQRS reporting.  PQRS stands for Physician Quality Reporting System – which means someone has defined quality and it is up to the doctors and their support staff to document such quality was rendered during the patient encounter.  Practices that do so for second half of 2014 will be eligible for a nice rebate check from CMS equal to 0.5% of their Medicare part B charges.

Is anyone actually checking with the patient to see if they feel better or their health was enhanced or that they left with better information, reassurance or more knowledge than before the visit?  No, not so much.  We just assume they got better because we used guidelines based on quality standards; by definition they received excellent care!  I must clarify that last statement: The urgent care staff does call the patient the next day to check progress, not to mention the patient is surveyed to death for the next two weeks.  But those reports don’t go to the government.  Those are used for marketing pitches if the feedback is good and corrective action if not so good.

Now to be fair, the doctors I referred to in the leadership positions are good physicians and are very diligent professionals who work very hard at what they do.  However, I think they may be a little shortsighted in this decision to accept the bribe from Uncle Sam.  Not to mention it is just one more piece of administrative work that I have to do (that has nothing whatsoever to do with being a doctor and treating patients, but I digress) in the form of a charting requirement made all-so-easy by the fact that they have a meaningful use compliant EHR.  How convenient!

So in the spirit of professional collegiality, here is how they created incentive for us to make sure we reported the appropriate data on every patient, every time:

And I quote, “Noncompliance with this protocol costs (acme urgent care) money. We will not garnish wages but repeated noncompliance will lead to disciplinary action up to and including termination.”

I am not making this up.  That line was in the email.  Maybe it’s just me, but offering a share of the loot in turn for our diligent cooperation would have been a tad bit more motivating.

But seriously, I really fear for the future our profession.  I fear we are making a pact with a partner (CMS) that we may regret and never recover from.

Is this what it takes for a medical practice to survive now – a 0.5% Medicare claims rebate, and in years to come be victims of extortion in the form of withholds for non-compliance?  How much longer until the only thing payers pay for are treatments based solely and exclusively on a check list, easily rendered by minimally trained para-professionals.

I’ll gladly give it back if you’ll just go away and let me practice medicine! Ouch, take it easy with the pitch fork!

What happens when (not if) we have to deviate from these “quality” treatments based on better evidence that is not yet been vetted and widely accepted?  Will we get rewarded for this approach?  I think not.  It will likely be just the opposite.  The best and newest approaches often take years to make it to the level of “standard of care”.  Will innovators get a retroactive check with interest for lost reimbursements and an apology the HHS secretary?  Not likely.

This data will, at some point in time, be used punitively against those that are collecting it – in the form of more mandates, compliance protocols and eventually tying it all credentialing or maybe even licensure (if CMS has its way).  And patients?  They won’t be any healthier.  They will, however, have fewer choices of providers on a diminishing menu and be victims of another bumbling federal bureaucracy, which approves reimbursements for only certain treatments that are likely outdated and non-individualized, just as long as we check the right box!

In my opinion, PQRS is a colossal waste of time, talent and resources.  It is not what I am supposed to be doing as a doctor.  I am supposed to work for patients, not reporting to a government overseer just so I can eek back a portion of what they determine I am worth.

For more on the topic of paying for performance, outcomes and the consequences of following preordained treatment protocols, see the excellent articles at the links below:

http://healthblog.ncpa.org/whats-wrong-with-pay-for-performance/

http://www.bmj.com/node/529749

http://www.kevinmd.com/blog/2014/06/doctors-paid-outcomes.html

I feel much better now; thanks for listening.