Part 3 of the ACA Series: The Puzzle of Value

Since the ACA plans to pay physicians based on quality and value, it is vital that we determine how these terms are defined and measured. We have already discussed that the ACA’s conception of quality, demonstrated by proving adherence to Medicare’s quality indicators and the “meaningful use” of electronic medical records (EMR), verges far from genuine geriatric quality care, and often even leads to poor quality. More significantly, doctors squander valuable time having to prove their compliance with quality indicators and EMR requirements, time that could otherwise be spent discussing important issues with their patients and contending with their patients’ chronic illnesses comprehensively and sensibly, time that is valued by doctor and patient alike and that represents real quality care. In fact, it is often chronic illness that most impacts the very value that the ACA is trying to gauge. A recent Medscape article showed that patients with chronic disease utilize the majority of the entire US health care expenditure, with the per capita cost of those with multiple chronic diseases on average twice those of the average American (2/28/15). In my book I discuss the huge cost that the sickest people incur on our medical system, and the fact that Medicare pays a quarter of its budget treating end of life conditions, primarily in people with chronic disease.

Almost the entirety of the ACA’s thrust to grade doctors on the value of their work revolves around their management of chronic disease. It is believed that if doctors can better manage the chronic illnesses within their population of patients, then they will save money, and Medicare plans to filter some of that money back to doctors as shared savings, thus incentivizing doctors to be more vigilant in managing chronic disease. That shared savings, in fact, will constitute a majority of primary care pay if the ACA formula is enacted. But there is a major problem with this approach. Doctors lack the tools and resources to actually accomplish the goal upon which they will be graded. In fact, so much else in the ACA universe actually thwarts doctors from managing their patients effectively and cheaply that doctors have a difficult time accomplishing “high value” care despite their best efforts. Also, it is unclear how primary care doctors, specialists, and hospitals will share the savings, and how they are each expected to contribute to the overall goal. Patients, meanwhile, have no barriers to continue pursuing poor quality and expensive care, and have no incentive to pursue high quality and low cost care; value, to patients, is often the very antithesis of how the ACA defines value, and patients are encouraged to spend health dollars freely, as we have discussed. For older patients, Medicare has not changed its face; they can be tested, treated, hospitalized, specialized, and pulverized as much as they want, and Medicare will continue paying without restriction, even if such aggressive care lacks both quality and value. In fact, if patients chose to exhaust the health care system of its resources even if they are harming themselves in the process, it will be their doctors who pay the price, not them, under the novel ACA “value-based” payment system.

We will discuss several reasons why the ACA quest for value will not work under its current construct. Consequently, physician pay, which will be tied to measures of value that doctors will be unable to control, will be in grave jeopardy, and there is very little doctors can do to alter that reality. The main areas of concern are: A lack of tools to achieve value, the conflict between “quality” and “value,” and the potential legal peril of shared savings.

THE LACK OF TOOLS: We have already talked about some of the methods that the ACA is using and studying to help physicians to combat chronic illness and improve the value of their care. These include medical home models, accountable care organizations (ACO’s), payment for chronic care coordination (the chronic care note), and pay for good transition of care from the hospital to home. Unfortunately, as we have discussed, none of these tools has been shown to save money, and most minimally impact hospitalization. Bottom line: if we can keep people out of the hospital we will be cutting cost, and thus that is the real measure of value as defined by the ACA. I will be writing more about chronic care notes and transition of care plans in a future blog, but suffice it to say that these very complicated payment systems are not only difficult to decipher by the average primary care doctor (we have been trying for months), are frequently not paid by Medicare due to their bizarre requirements, and are sitting ducks for Medicare audits, but more significantly they have never been demonstrated to reduce hospitalization or improve care for people with chronic conditions.

ACO’s and medical homes rely on care coordinators and nurses to reach out to high risk patients with chronic illness to help them manage medicines, assess their conditions, and get to doctor appointments. But if a patient needs medical treatment at home such as health aides, IV treatment, home health equipment, and expensive medicines, these novel ACA programs are unable to provide such care. It is far easier and cheaper for a patient to call 911 than to receive treatment at home, and none of the ACA programs at all alter that reality. And since patients have no skin in the game, and since under the ACA “value” system doctors are responsible for their patients’ choices, the lack of resources we have to help keep patients at home is perverse because we cannot stop patients from rushing to the hospital, which of course is the easiest and least costly option for them virtually always. By making it so difficult to treat our patients at home, and by making it so easy for patients to receive hospital care, the current Medicare system, which has not been altered by the ACA, is basing our pay on an impossible task. You can throw as many programs and acronyms at us as you want, but until the payment structure is altered for both doctor and patient that makes home care easier and less expensive than hospital care, the status quo will persevere, and doctors will be financially punished for something they cannot control.

THE CLASH OF VALUE AND QUALITY: Doctors need to spend so much time documenting quality, that we have no time to provide valuable care to our patients. We have no time to discuss the risks and benefits of medicines and tests, no time to spend with our patients to determine the best way to manage their chronic conditions, no time to develop the type of trusting relationships with our patients that truly will help us to cut costs and increase genuine quality. Time is what doctors and patients want and need; it is the very ingredient that allows us to keep people healthy and out of the hospital. Our mandated need to document quality indicators directly slashes that time. Quality indicators are generic; they do not consider that each patient has individual needs and wants, many of which verge from what the indicators mandate. For instance, I have patients who do best when their sugars and pressures run high, when they are not taking statins, when they stay away from tests that make them nervous. And yet to be compliant with Medicare’s indicators I must use statins in certain circumstances, keep the blood pressure and sugar low, order multiple tests, and carry on a conversation with my patients that is scripted by Medicare and often has no relevance to what they or I want to discuss. By having to follow templates mandated by quality indicators, we actually may be causing harm to many of our patients with chronic disease, and this could lead to an increase in sickness and hospitalization. Studies bear out this fact, as I discuss at length in my book. Rather than addressing the genuine needs of each of our patients, something that could well help them to be healthier and happier, we are forced to treat every one of our patients as Medicare tells us to do. Quality, then, defeats value.

Many of the programs that the ACA has devised to enhance value are predicated on the theory that increased surveillance will lead to better outcome, something again that has never been demonstrated to be true. Thus, if a nurse visits a non-compliant patient with chronic illness, and that nurse works to control sugar and blood pressure and fluid overload aggressively, then the patient will be healthier and stay out of the hospital. Is this true? Sometimes it is, but sometimes it is not. Again, there is just so much a nurse can do, and so when a patient needs resources to achieve the ascribed goals, Medicare does not provide the nurse or doctor meaningful tools to really help; in fact, the ACA has made it more difficult to obtain many crucial home services. And too, because such nurses also must comply with quality indicators, sometimes they push the sugars and pressures too low, sometimes they over-treat fluid overload and cause dehydration, sometimes they panic and send people to the hospital for aberrant numbers that in fact are not very dangerous for that particular patient. In other words, in some instances, their very presence may lead to more hospitalization and illness due to the irrelevant quality indicators to which we all must comply. By giving them no resources, and by having them adhere to generic renditions of quality that can be injurious to the patients they are trying to help, the ACO and medical home nurses cannot improve value on a significant scale, and nor can the doctors working with them.

THE LEGAL CONUNDRUM: Of course, the ACA did not address any malpractice reform, something absolutely essential if we are going to have a functioning health care delivery system. I spend a large part of a chapter in my book discussing this, but for the purpose of this blog let me propose one possible scenario that could unravel the entire concept of shared savings. Let’s say I am taking care of a population of patients and that a large part of my pay is based on shared savings: keeping people out of the hospital. One of my patients has multiple chronic illnesses, and we have an ACO nurse visit him, we provide some basic home care, and we try to treat him at home, because that is the safest place for him to be. But then he dies. His family sues, and the case goes to court. The prosecuting attorney turns to the jury and says: “Are you aware that by keeping this sick, elderly man at home and not putting him in the hospital where he needed to be, that Dr. Lazris actually was given more money by Medicare. Yes, Dr. Lazris became richer when he denied this victim appropriate care in the hospital.” Enough said about that. Shared savings is a law suit waiting to happen. And in our current legal system, no doctor has a chance when prosecutors are given that type of ammunition to influence juries!

IN SUMMARY we cannot provide medical care that has any value in the current ACA environment unless profound bottom-up changes in health care delivery and reimbursement occur. By punishing us financially if we do not cut cost, while providing us with ineffective tools that are overly-complicated and do not allow us to treat people at home, forcing us to adhere to dictates of quality that may actually make our patients sicker, giving us no time to discuss issues with our patients and their families, incentivizing patients to use the hospital for their care and giving them no skin in the game, making us legally liable should a poor outcome occur at home, and continuing to finance aggressive hospital-based care and not home care, the ACA is holding us accountable for something they have made impossible to achieve. Instead of trying to define value by acronyms and bizarre and complicated programs, while pretending to advocate for quality care when in fact placing insurmountable barriers to true quality, the ACA needs to talk to primary care doctors who live and work within the health care system. We do know the answer; my book, and many others, makes that very clear. And it is much simpler than current ACA reforms would have us believe. Rather than impose top-down approaches on us composed by people who do not know what it is like to practice medicine, just ask us how to best take care of our patients. Afterall, that is what we do, every single day.

For another excellent blog on value, see Dr. Steve Schimpff's blog in Primary Care Progress. Just CLICK THIS LINK to see it.