Medicare's Quality Indicators and the reduction of quality geriatric care

What are quality indicators? Essentially Medicare and the ACA are attempting to assure that we doctors practice quality medicine, and they have established means to monitor us through quality indicators. On the surface, that sounds like a very noble cause. But unfortunately, the quest to enforce quality is leading us to just the opposite pole. We have talked about the quest for numerical perfection and how much of a folly that is for older patients. Yet, many quality indicators are focused on numbers: achieving “ideal” blood pressure, measuring and treating cholesterol, measuring and treating bone density, and more. Doctors are rewarded for pursuing the very naïve number chasing that I have debunked in my book and on this blog. Quality indicators also push us to order more tests. But most concerning, there is nothing in Medicare’s quality indicators that encourages us to do less. Nothing that tells us to back off, to not obsess about numbers when people age, to reduce medicines, to order fewer tests. Nothing that encourages us to help our patients have meaningful, active lives without searching for evasive (and often dangerous) fountains of youth. In other words, quality indicators do nothing to promote geriatric quality; they do just the opposite. What is worse, is that through the ACA and its Accountable Care Organizations (ACO), and through Medicare reform both in the PQRS and Meaningful Use programs, we primary care doctors are going to be paid based on how compliant we are with Medicare’s quality indicators, not by how well we take care of our patients. Now we must check boxes, engage in meaningless tasks, follow templates, and squander a large part of our day “proving” that we are practicing quality medicine, as we stare at a computer screening typing in notes, spending much of our day following Medicare’s script rather than talking to our patients and practicing sensible medical care. Real quality—compassionate and personal health care—has evaporated amidst Medicare’s quality campaign. As we move forward in this blog, we will talk about how the culture of Medicare has defined quality as being the pursuit of thorough, and has defined thorough as the practice of aggressive medical care. The result is more tests, procedures, specialization, hospitalization, and medicines. Medicare has done nothing to stop our leap into the world of expensive and ineffective medical care, while actually using its quality indicators, and other financial incentives, to push us to do just the opposite.

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