The Behavioral Medicine Report

The following is a response to and further analysis of the recent BMED Report article, “Efforts To Promote Use Of Lower-Cost Physicians May Be Based On Misleading Profiles.” My original intention was to provide only a brief comment, but as it became apparent that my response contributed meaningful new information and at the urging of the Managing Editor (Christopher Fisher, PhD), I decided to make this response my first full article for BMED Report.

Without further delay, it is not surprising that cost analysis among physicians is not a reliable marker of quality. The true marker which everyone looks for is “the highest quality physician care for the lowest cost.” However, no algorithm to date has been able to successfully decipher these qualities amongst doctors. Serious efforts are underway at Centers for Medicare and Medicaid (CMS) to create this benchmark as health care costs continue to soar.

CMS currently uses a system called Physician Quality Reporting Initiative (PQRI). This system, in theory, is plausible; however, CMS seems to approach analysis from a monetary standpoint, which blurs the quality of care. Here is a basic example of how it works: A physician or group registers for PQRI through CMS (it is currently voluntary). Then over the next year they must report on every patient regarding certain core measures: 216 for the year 2010. These measures range from depression to urinary incontinence to electronic medical records and everything in between. The physician is encouraged to report 3 or more of the 216 measures on at least 80% of patients to meet compliance. If the doctor reaches this compliance, they will receive a 2% “bonus” of all Medicare collected receipts for their tax ID number.

For a real world example, a Urologist has met compliance when a female patient, age 65 years or older, is asked about urinary incontinence (measure 48), diagnoses the type of incontinence (measure 49), and creates a plan for treatment (measure 50). That sounds pretty simple, and it is. Why would the government offer extra money for this relatively normal interview? Well, first it applies to all physicians, so they are actually targeting primary care more than specialists. It would be hard to believe that a urologist would not inquire about, nor offer to treat urinary incontinence. Next, it saves CMS money. Older women with incontinence have 3 choices: treatment, absorbency pads, or run to restroom. It turns out that treatment is the cheapest option; no surprise because CMS wants to reward doctors for addressing it. Absorbency pads are expensive and the cost is solely the patient’s responsibility (i.e., not covered by insurance). Each absorbency pad may cost up to $1 per pad, and a patient may use 3-5 pads per day. That is $90-$150 per month for pads in a population that usually has a fixed income. Instead, many senior women opt to go without the pad, and run to the restroom. This is the most expensive treatment for CMS because for everyone women that runs and subsequently falls and fractures a hip, it costs CMS several thousands of dollars in medical expenses related to these injuries. If the same women is started on a medication for $20 per month and lives 20 years, it only costs $4800. Now you can easily see their interest in treatment.

The question raised is, “Why is this bad? How does this negatively impact quality care?” First the idea is not bad. It is well established that preventive medicine saves money and improves quality of life. As an osteopathic, urologic surgery resident, it is one of my core tenants to provide preventive medicine. The problem is the means to the end. In some states, various insurance companies require all physicians in the state to participate in PQRI. The insurance company then rates physicians from 1 to 5 (best to worst depending on PQRI reporting numbers). Then they assign copays to each physician accordingly. For example, the physician rate #1 category has a patient copay of $5 and the physician #5 category has a $100 co-pay. The patients may choose any physician, but they are much more likely to select a higher ranked doctor (based on PQRI alone) because of copay rates and artificial quality rankings. Physicians that do not volunteer to participate in the PQRI CMS system are automatically rated at the #5 category. Once a physician is rated #5, the only way to become re-rated is obtain electronic medical records, which easily costs $50,000+. As you can ascertain, CMS is trying to force physicians into this system via financial avenues; be it right or wrong.

Regarding quality of care, a patient looks in their insurance book for a doctor and has to not only choose a doctor rated #1-5, but also what co-pay their are willing to pay. On the surface, why would one pay more for a “bad doctor?” In reality, are all the good doctors in the #1 category? And the bad doctors in the #5 category? Absolutely not. They are just meeting or not meeting the requirements demanded upon them by insurance companies and CMS. Potentially, a doctor rated in the #1 category could get the required 3 measures, misdiagnose and mistreat your disease process with the most expensive treatment, and stay #1. Obviously quality, cost effectiveness, patient care, and quality of life are not aligned in this scenario.

As a resident surgeon, I cannot participate in PQRI as I have an educational license and do not bill any patient for my care. Also, a little known fact is that my paycheck actually originates from CMS. I want to be clear that I am not saying CMS is wrong for starting PQRI, as I agree with the ideology of preventive care and lowering the cost of health care. However, I disagree with it being tied to rankings that are artificial and monetarily gain incentivized. These rankings give patients a false sense of quality care. They are simply established to save insurance and CMS money. I guarantee that some of the highest quality care I have given patients did not include these ever expanding, but limited, core measures.

This leads us back to where we started; how do we rank physicians for the highest quality of care with the lowest health care cost? I am not sure that I have the answer, but PQRI and other systems do not either. I believe the rankings should be a sophisticated algorithm of preventive care, evidence based medicine, patient outcomes, patient population, and over health care cost. Patient population is included because as physicians become ranked, especially surgeons, there is a drive to “cherry pick” patients for surgery (i.e., do not offer surgery to high risk patients as they may lower rankings disproportionately even though they are in the most need for an intervention). The idea of demanding high quality care and cost effective medicine is a necessity. Unfortunately, the means to develop this in a tangible manner seems out of our grasps at the present time.

Jason D. Fisher, DO, MBA
Urological Surgery Resident

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