Carrot and stick

[DrWinn]

Well, I just got back from a meeting in Washington with the powers that be. Before anyone gets too riled up about some of the proposals, remember these ideas are presented in the interest of improving patient care. Here goes.
Some of the names were CMS head Dr. McClellan, Bush EHR appointee Dr Brailer, congresswoman Nancy Johnson and AMA consortium leader, Dr. Hellman. It appears that the game plan is something I previously predicted, the carrot and the stick. Pilot programs in different parts of the country are measuring physician adherence to best practices for certain chronic diseases like diabetes and CHF. The physicians that demonstrate good patient compliance for certain performance benchmarks like HgbA1c measuring (and levels) or good BP control will receive bonuses of between $5,000 - $20,000. That's good. Now for the 'stick' (if you are an underperforming physician). If your patient panel does not meet a certain minimum threshold in quality of care measurements, CMS and/or participating insurance companies will contact your patients and offer to pay the co-pay for them if they switch to a high performing physician. While this sounds very 'big brotherish', it should help to raise the bar in quality of care. My only concern is that the govment will eventually eliminate the carrot and just use the stick....
By the way, I'm just the messenger - so please don't shoot.

[pprescot]

Uh, could you clarify a few points if possible?
Let's say the standard for DM is an A1C every 6 months.

1. Does the standard include a level expected, i.e., some % within normal?

2. Suppose I order A1C 100% by standard, but only 40% of patients get it done, no matter how much I rant and rave. Is that marked against me? Or is it the ordering that counts? Or can the patients be "stick penalized" in some fashion for being out of compliance?

3. If the standard includes some % within normal range, and I order it 100% of the time, and 100% of the patients get it done, but only 30% are in the "normal" range because, despite my ranting and raving, they simply don't take their meds, don't eat right, etc., who gets the "stick?"

In other words will the standrads measure what I can actually accomplish in the real world, or some bureaucrats ideal of medical compliance and results - the latter really depending on our patients?

[Kursk]

No surprise here.

There will be no 'bonus', just a redistribution. Classic adminstrative slight of hand.

Those already struggling will be put out of business, unable to purchase the time and technology needed to implement changes.

Patients held blameless for their noncompliance, doctors punished if they discharge or 'dump' them, no patient profiling allowed.

Smart docs will do the minimum established to get paid and ignore the rest, cherry pick agressively.

This is the most agressive intrusion into business ever seen and would not be tolerated by ANY other industry. Raise the spector of patient safety and take over an entire industry with no track record of success, complete control and no performance review (just blame the doctors if anything goes wrong)!

Bloody Brilliant in Machievellian way!

[bioisnonsense]

I'm just the messenger - so please don't shoot.

OK.

This is crazy.

Measuring doctors performance as though they were shoe salesmen or factory workers. Shoe salesmen too would be unhappy if they were being monitored in this inhumane fashion. Assembly line workers ARE unhappy when treated this way. Everyone wants some dignity. No one wants to be treated like a robot.

Even more so when it comes to doctors, who are supposed to in a position of power over other peoples lives. What insanity is this to deprive doctors of their power and dignity? How can you be the treater of other people when you yourself are being harrassed in this manner?!

And I think we're already 85% there...

:mad:


Thinking that medicine can be run as though it is a business, by the same rules that any corporation would run its business. Any large, grey corporation run by managers who lack vision, that is...

Doctors are supposed to be healers. Medicine is an art. It's one human being treating another.

'Demonstrate compliance'...

'Quality of care measurements'

>>it should help to raise the bar in quality of care<<

Surely, thou jest.

I have no words to tell you how much this disgusts me.

OCPD'ish Megalomaniacs. Micromanagers. Number crunching grey suits. That's what these people are. Not a shred of understanding as to what motivates people. What discourages them. No comprehension as to what medicine is. Power hungry beaurocrats. Nobodies. Worthless. The sort of people who will bring medicine in this country from the deep crisis in which it is now in to a total shut down.

Could you make doctors any more unhappy than they are now?

And why are you doing everything in your power to increase doctors unhappiness? What form of madness is this?



:mad:

[Kursk]

I say carrot and stick the patient! He has the most at stake - the greatest benefit and risk!

[bioisnonsense]

pprescot, give me two of whatever your cat there had, please.

I think I need it.

[Kursk]

bioisnonsense: you just don't get it. They are saving people. You can't just stand by and watch people die can you? Not when you can take over and make it right! Getting A1Cs quarterly will cure diabetes, its proven. Its not the patient, its not the donuts, its not the cost of medicine, its not the declining reimbursement, its the damn greedy doctors!

[pprescot]

pprescot, give me two of whatever your cat there had, please.

I think I need it.

Well, let's see, one's a Miller Light and the other's a remote control. In the 60s and 70s I was a liberal, in the 80s a moderate, in the 90s a conservative, now.... I just watch movies.

Join me. Methinks we dost protest too much. The country is in the hands of a drunken failure who has been "saved," neoconservatives who see the US as the world's policemen (and heaven help you if you disagree with us), and morons who write rules but never work in the real world (HIPAA, JCAHO, and the coming rules for "monitoring" our compliance with standards while passing on the "savings" to the HMO CEOs and the companies that will make a fortune on the new software and comnputer sytems this will require).

Join me in Costa Rica, great place to retire!!!

[pprescot]

I say carrot and stick the patient! He has the most at stake - the greatest benefit and risk!

Exactly my point. My post requires initial and yearly PFTs for asthmatics ('tho yearly isn't even recommended by pulmonologists). I order it to be in compliance. Patients don't make appointments, miss scheduled appointments, etc etc etc. Is this MY fault? But then, you're not responsible for holding hot coffee in your lap in a moving car. Guess it is my fault.

Am I "jaded?" D*** right!

Monitoring competency in practice doesn't really bother me. I AM tired of seeing CIPRO prescribed for a cold! But -- do I think this will be done in any reasonable fashion? Yeah, right.

[DrWinn]

Uh, could you clarify a few points if possible?
Let's say the standard for DM is an A1C every 6 months.

1. Does the standard include a level expected, i.e., some % within normal?

2. Suppose I order A1C 100% by standard, but only 40% of patients get it done, no matter how much I rant and rave. Is that marked against me? Or is it the ordering that counts? Or can the patients be "stick penalized" in some fashion for being out of compliance?

3. If the standard includes some % within normal range, and I order it 100% of the time, and 100% of the patients get it done, but only 30% are in the "normal" range because, despite my ranting and raving, they simply don't take their meds, don't eat right, etc., who gets the "stick?"

In other words will the standrads measure what I can actually accomplish in the real world, or some bureaucrats ideal of medical compliance and results - the latter really depending on our patients?

Whoa, this sure touched some nerves. The people behind the 'standards' setting are practicing physicians. Dr. Hellman with the AMA consortium for quality measures, and with whom I had a slight disagreement with how rigorous these requirements were, is an endocrinologist.
They did anticipate that some doctors might 'cherry pick' patients based on poor compliance, so their first suggestion was that physicians might have their profile adjusted by requesting a lower QOC rating based on a higher non-compliant patient population. I think this is arbitrary and a bit ridiculous. My suggestion was that a physician simply have a check-box to track patients that are either #1 non-compliant with whatever (diet, exercise, testing) or #2 refuse (which is kinda like a stronger version of non-compliant) and gets these folks excluded from the 'threshold'. I hope a more reproducible and verifiable tracking measure is used. The next question was HgbA1c levels and % of patients that get tested for this and that. Here the govment will set rather low thresholds. Say 75% of your diabetics get their HgbA1c done quarterly and, of those, 50% are below 8. If 75% of your 'uncontrolled' patient population was getting quarterly testing then you would meet the bar and get a perfect rating. My biggest fear here is that the measures will be based on what an endocrinologist sees as reasonable which may be a little harder to achieve for us internists and FPs.
The vendors are starting to coordinate their efforts in the hopes that a unified voice will keep the requirements from getting too far out of hand. Dr. Andy Ury (CEO of PMSI) and I have discussed how too many measurements might bog down data collection in an EMR and defeat the purpose of the EMR to actually speed up documentation. Dr. Ury has been involved with one standards committee and successfully got the 'academics' to back down from their proposed 1,300 element data set that they were seeking to capture in patient records. You and I know that any requirement to collect more than 10 to 15 items (ie. patient is A. Smoker or B. Non-smoker) will probably slow down the encounter too much and impact patient thruput.
Last but not least. MEDEM is a for profit spin-off of the AMA. These guys have come up with a pretty brilliant game plan. They envision that the patient has his/her own patient health record and that they do essentially all the work. The goal is for the patient to have a secure web site at MEDEM where they control the record. They can grant access rights to a physician - or deny them. When scripts are written by different physicians, the new meds are automatically updated on the site. The goal is that eventually everything done to a patient eventually winds its way into their web health record in an organized method (ie. xray reports under a radiology tab). With new patient visits, a doctor using an EMR would hit this site and the EMR would be automatically populated - and then the PHR (patient health record) would be updated by the same EMR at the conclusion of the visit. Their are some potential problems that MEDEM still needs to work thru - like how do you keep the patient from deleting the history you recorded of their 'binge drinking episode and subsequent GI bleed. I had a patient ask me to alter his record once over this exact issue because he was applying for life insurance.
Anywy, if I understand it correctly, MEDEM will be free to patients and their docs.
The AMA and MEDEM have successfully lobbied the govment to include a CPT code for econsults. The goal is to get physicians paid for use of email. The damn lawyers get paid for every second of their time - it's time we start getting paid for non-face to face encounters too. I got to meet the leaders of the AMA. They are very down to earth and genuine folks and practicing physicians like the rest of us (well, me excluded for the last 5 years). The AMA is under attack just like the rest of us. They are walking a fine line of trying to represent the best interests of physicians without losing the support of people in the govment that might otherwise view all of us as a bunch of 'greedy' doctors. I think the gist of all of this is that a lot of sincere, good people are trying to improve the quality of health care. That requires changes on a lot of fronts (like better access for the 45 million uninsured). Quality measurements are an integral part of this equation and whether it's done by paper, the EMR, the PHR or some other mechanism, it is the only way to know if we are making headway. Perhaps technology will usher in enough savings that the govment can use more of the carrot and less of the stick.... nah, that will never happen. :rolleyes:

[Tim2]

It may be a naive question, but will this effort make the fall between the cracks patients a larger pot? If so, it seems like this may be job security for me. The psychiatrically impoverished have few allies.

[pprescot]

Glad I'll be retiring before this monster ever hits the streets.

I sure do favor some sort of national health record. In pediatrics especially, tracking immunizations is the biggest pain in the a**. Would be nice to vist a web site and see all shots given anywhere, anytime.

As for the rest of it.....especially the "quality assurance" part, I see too many potential blunders, areas for fraud, etc etc etc.

Had a patient in clinic who was altering her record everytime she got ahold of it to take somewhere else. White out, pages removed, annotations put in in red ink. Yeah, pt. access to their records is a fine idea.

[DrWinn]

Here's a post from elmr - Wall Street Journal article.

Oops - I got this error message The text that you have entered is too long (15103 characters). Please shorten it to 10500 characters long.

Try hitting this link instead
http://www.emrupdate.com/forum/topic.asp?TOPIC_ID=1914

[bioisnonsense]

>>MEDEM is a for profit spin-off of the AMA. These guys have come up with a pretty brilliant game plan. They envision that the patient has his/her own patient health record and that they do essentially all the work. The goal is for the patient to have a secure web site at MEDEM where they control the record. They can grant access rights to a physician - or deny them.<<

ROFLMAO!

Do you evaluate patients beforehand for psychosis/hypochondriasis/personality?


Literacy?

[BigDoc]

>>MEDEM is a for profit spin-off of the AMA. These guys have come up with a pretty brilliant game plan. They envision that the patient has his/her own patient health record and that they do essentially all the work. The goal is for the patient to have a secure web site at MEDEM where they control the record. They can grant access rights to a physician - or deny them.<<
ROFLMAO!
Do you evaluate patients beforehand for psychosis/hypochondriasis/personality?
Literacy?

The thought of relinquishing the chart to some 3rd party scares me :eek:

[bioisnonsense]

From the Article DrWinn linked to:

>>Proponents contend cash incentives are the only solution to the problem at the heart of the nation's health-care woes: a system that pays doctors who provide inadequate care the same as doctors who provide excellent care.<<

That is at the heart of the healthcare woes?

What genius came up with this?


I saw an excellent care system disintegrate before my eyes as it tried hysterically to meet more and more paperwork/beaurocratic demands. Most of the time there seemed devoted to increasing 'compliance' and other such rubbish and satisfying the various performance improvement criteria. Guess what, place closed down. Went from excellent to non existent over the course of a few short "performance improvement" years.

I suspect none of these people who come up with these brilliant ideas have the first clue about group processes, not to mention intrapersonal ones. In simple terms, you don't understand people. You just haven't got a clue.

[DrWinn]

>>MEDEM is a for profit spin-off of the AMA. These guys have come up with a pretty brilliant game plan. They envision that the patient has his/her own patient health record and that they do essentially all the work. The goal is for the patient to have a secure web site at MEDEM where they control the record. They can grant access rights to a physician - or deny them.<<

ROFLMAO!

Do you evaluate patients beforehand for psychosis/hypochondriasis/personality?


Literacy?

I have the same concerns. We have suggested to MEDEM that patients be able to append to (not delete or alter) a particular history element. I think MEDEM is wrestling with this same issue. If the solution is too restrictive to the patient, they will probably refuse to acknowledge or use the PHR. But a PHR, even flawed, is better than what we have today - nothing.
By the way, what does ROFLMAO stand for?

[DrWinn]

I saw an excellent care system disintegrate before my eyes as it tried hysterically to meet more and more paperwork/beaurocratic demands. Most of the time there seemed devoted to increasing 'compliance' and other such rubbish and satisfying the various performance improvement criteria. Guess what, place closed down. Went from excellent to non existent over the course of a few short "performance improvement" years.



Similar story - I know of a company that pulled out all stops to be ISO quality certified. They went from profitability to bankruptsy over the course of a couple years. Quality pays - but not if the cost becomes too great.

[Kursk]

Well itentioned? The road to hell?

Okay, of my multiple personalities, Ziggy has been especially hard to control after hearing this from one of the other guys.

Educate yourself on what is happening in oncology - coalitions are forming so smaller private practice is going goodbye. This is a survival technique given the unilateral bragaining power of insurance companies.

Hmmm. If I wanted to eliminate practice variability and encourage the accumulation of capital so medical practices could afford large outlays for computerization (which will allow me to contol their practice remotely), maybe I should eliminate these pesky little guys, force them into large cooperatives that I can control by monitoring their data .....

Stop saying carrot. As Neo would say, "there is no carrot". You know this will ONLY be punitive. They are NOT going to increase the amount of money coming into the system, they will not give up their margins to doctors and hospitals. You have seen decades of proof, why oh why do you so gladly go to the slaughter?

[Kursk]

ROFLMAO: rolling on the floor, need MAO inhibitor

[bioisnonsense]

Similar story - I know of a company that pulled out all stops to be ISO quality certified. They went from profitability to bankruptsy over the course of a couple years. Quality pays - but not if the cost becomes too great.

The point of my story was that the high quality could not be measured by any of the bean counters, and the attempt to squish it all into neat little boxes in order to satisfy the grey-suits was doomed to fail. And thus Good Place closed, leaving much devastation in its wake, because Good cannot be measured.

ROFLMAO = roll on the floor laugh me ass off.

[Tim2]

I sure do favor some sort of national health record. In pediatrics especially...

The kids have fewer allies.

[pprescot]

From the Article DrWinn linked to:

"with extra points for patient satisfaction and investing in new technology."
So we're back to pleasing patients rather than treating them. Must satisfy the masses. Even if they want things we don't feel are needed. And this new technology isn't going to come cheap. Who bears that cost?

"In addition, doctors say they don't have the technology to track follow-up care and shouldn't be held accountable for patients who simply don't do their part, by not taking medicine or going in for recommended tests....Doctors argue they can't force patients to come in for tests or screenings....and some patients simply didn't follow the doctor's advice. In one case, a doctor sent out reminders to 105 patients who were overdue for Pap smears and set aside extra time for appointments: only 12 patients called back and scheduled."
Exactly my point. Of course patients always tell the truth, right? "Yes doctor I take my blood pressure pills every day" as he sits there with a reading of 200/110. Patients need to be penalized, or at the very least, compliance has to be trackable. So, do we have blood level tests for Metformin, BP meds, etc? Rate docs based on patient satisfaction and their truthfulness regarding their own compliance? Yeah, that will work.

"Most ratings rely primarily on claims data -- the coded invoices that doctors submit for reimbursement, showing what services they performed. But critics say that data doesn't always reflect an individual patient's risks."
Nor does it acurately reflect diagnostic honesty, etc. Easy to scam a code based system. But, see above. We'll just ask the patients!

"Next year, in addition to just looking at whether doctors performed tests, the program will focus more on patient outcomes, including how well diabetics' blood-sugar and heart-patients' cholesterol are controlled."
See above. Guarantee patients actually check theitr blood sugars, bring in the reports, take their meds, follow their diet and exercise plan...Ah, but the patients aren't rated. Only we are.


Yep, we can't avoid the winds of change. This will probably be shoved down everyone's throats. In some cases I can see some good. But to me there are simply too many complications. Especially after guideline after guideline after guideline are added for "quality assurance." Computer systems will need massive storage and redundant backup. Much more than most now have.

And has anyone seriously addressed security?

[DrWinn]

ROFLMAO: rolling on the floor, need MAO inhibitor

Ahhh, the missing I threw me.... should be ROFLMAOI :cool:

[Tim2]

Hmmm. If I wanted to eliminate practice variability and encourage the accumulation of capital so medical practices could afford large outlays for computerization (which will allow me to contol their practice remotely), maybe I should eliminate these pesky little guys, force them into large cooperatives that I can control by monitoring their data .....

Stop saying carrot. As Neo would say, "there is no carrot". You know this will ONLY be punitive. They are NOT going to increase the amount of money coming into the system, they will not give up their margins to doctors and hospitals. You have seen decades of proof, why oh why do you so gladly go to the slaughter?

As Ripley would say, "The Company"

[BigDoc]

We hope there is no hidden agenda, see Kursk's post (http://www.docsboard.com/forums/showpost.php?p=9211&postcount=6) :eek:

[DrWinn]

We hope there is no hidden agenda, see Kursk's post (http://www.docsboard.com/forums/showpost.php?p=9211&postcount=6) :eek:

I too tend to be a cynic. The govment has proven that HIT saves money (and lives), but they will find another use for that money than giving it back to the docs. Frankly, I think healthcare is so screwed up that we ought to just thrash it and start over. Just think of the savings if we got rid of the insurance companies. Of course, that would beget a single payor system with the inevitable mediocrity. Smart kids would go to Wall Street, not medical school. Who in their right mind would endure 8 years of medical school/residency, piles of debt, a crappy lifestyle, declining respect and the perpetual spectre of malpractice suits? Maybe we should be targeting masochists to be America's future doctors. Of course, all of this is probably moot. Our destiny is already set. The battle for our future was fought and lost on a day in February, 1946. On that day the first computer, Eniac, was born. Computers will eventually become smarter than people and will simply be supervisors of physician extenders that provide medical care at bargain basement prices. What a wonderful future. Does Nardil work for terminal cynicism?

In eo est adeo postmodo demorior, consaluto
Those of us who are about to die, salute you.

[Kursk]

>The govment has proven that HIT saves money (and lives), but they will find another use for that money than giving it back to the docs.<

You betcha. They have already sacrificed rural hospitals. I heard on NPR how doctors "stole" money from medicare patients by "artfully" getting the reimbursement cuts delayed. They have the big pharma boon to pay off (medicare drug benefit). They are offering better deals to the insurers to get them back into medicare.

Read my lips: no more taxes

The money will not flow to doctors, it will just be pushed around, favoring larger clinics that can be controlled easier.

Lies, lies and the lying liars that tell them.

But, hell that's just me, what do I know I could be wrong. [/rant]

[DrWinn]

FYI

http://www.dwt.com/practc/hit/bulletins/09-04_healthrecords.htm

[pprescot]

FYI

http://www.dwt.com/practc/hit/bulletins/09-04_healthrecords.htm

From the above:
"Individual Rights over Health Information in EHR Networks. Current regulatory schemes place ownership of the health record with the provider, and give consumers limited rights to see, copy and amend their health records. In discussions about the NHII, there is a strong theme of consumer involvement and empowerment. What does ownership of the health record mean? What rights do consumers have today? Should they have stronger rights over information in a shared EHR - for example, the right to keep their health records out of the system, or to exclude certain information, such as mental health records, genetic information and the like? Should they be able to restrict access to their records by certain providers, or by non-providers, such as public health authorities? "

Exactly. Right now the record is the property of the doc/clinic. The patient has the right to a copy, but has no right to say what I put in it, etc. Give patients the right to exclude information, change information, or limit my access to it if I am their provider and I may as well sign all my assets over to the malpractice attorneys right now. Let's face it. Patients lie all the time about what they take, how they live, etc. As long as we rely on their word we're "safe" in a sense. If we have to rely on possible tainted records - look out.

EMR must be completely secure once entered and not subject to change by anyone. Annotated, added to, yes, but never changed or limited.

Now, guarantee that security on tens of thopusands of computers, most of which probably never get even Microsoft's numerous patches. On a too easily hackable internet.

I like the concept, but the implementation scares me.



"