There is no question that CMS has every right to demand better value in health care. Medicare’s coffers are being drained, as a significant amount of funding is being spent on fruitless efforts to keep people alive in their last weeks of life, on expensive tests and procedures that have no proven efficacy, on needless hospitalization, and on a proliferation of specialization that increases cost with worse outcomes. The Institute of Medicine estimated that in 2009 there was $750 billion of waste in medical care; it is felt to be approximately $1 Trillion now. A quarter of Medicare’s budget is spent on end of life care, and while the average Medicare recipient puts $88,000 into Medicare, he/she spends $380,000. So how do we cut the waste and improve the efficiency of medical care under Medicare? One would assume that in the CMS quest for value this question would be addressed. But in the Orwellian world of MIPS, “value” is not what we typically think it should be.
Value is embroidered into several sections of the MIPS report card. Doctors will be judged by how much their patients cost the system. If they have a group of patients who are high spenders, then they will be considered to be low-value doctors and receive a failing grade. It is also felt that doctors who “meaningfully” use their electronic medical records (another grade on the MIPS report card) are practicing value-driven medicine, even though there is no evidence that computers in the office help save any money. Finally, doctors who join alternative programs such as Accountable Care Organizations (ACO’s) could be exempt from MIPS and achieve “value” in other ways, much as some Medicare HMO’s are doing even now. I talk about many of these topics in my book (especially Chapter 6: Quality and Value, Moving Toward a Cure), but here are a few points about how the MIPS value scheme does and does not actually move us toward a more efficient health care system. In fact, due to the overtreatment that is encouraged by its quality indicators, MIPS likely will accomplish just the opposite. However, there is some potential for progress outside of the strict construct of MIPS, and that is what we hope to latch onto to achieve real value in health care.
Doctors are Rewarded to Take Care of Healthier Patients. Because docs/np’s are paid more if their patients spend less, then high-spending patients will harm practitioners in MIPS. Who are high-spending patients? Generally people with difficult social situations, the elderly, people who are poor, people who have severe chronic illness (congestive heart failure, poorly controlled diabetes, asthma, cancer, sickle cell anemia, ect), and people who are homebound. Thus, it behooves medical practitioners to stop taking care of “difficult” patients and concentrate on “easy” patients. Better to be a doctor in a middle class white suburban neighborhood caring for younger Medicare patients than a doctor who is in an inner city or a doctor caring for the elderly some of whom are home bound or in assisted living facilities (which is what I do) or a doctor who wants to take care of our sickest patients. Value, then, means to not try to help our most needy patients. Therefore, those patients will be neglected and continue to cost our medical system needless amounts of money by going to the emergency room incessantly and being sicker than they need to be. Like with quality indicators, MIPS rewards doctors who do the wrong thing.
Doctors will have to Pay the Price of Costly Specialty Care. Specialists cost the system more money than do primary care doctors. They order more tests/procedures, hospitalize patients more, and treat patients more aggressively, all at higher cost and worst outcome. This reality has been demonstrated by many population studies, especially those from the Dartmouth Institute, and is discussed in detail in my book. Just this week, specialists sent two of my patients to the hospital who I would have preferred to take care of at home, at a cost of tens of thousands of dollars per patient. But now, under MIPS, I will have to pay the price of those unnecessary visits. Because all of my patients who spend Medicare money detract from my value score, I will be liable for the excess care practiced by their specialists. In an irony that MIPS does not even consider, specialists will be financially rewarded by over-treating and over-hospitalizing their patients, but I will be financially punished because somehow I am responsible for whatever specialists do. Until you also give specialists some skin in the game and stop rewarding them for their excess, there is no chance we as primary care doctors can curb it. Why, then, should we be docked pay for what they do?
Doctors will have to Pay the Price of Patients’ Decisions. Similarly, if a patient decides to see 10 specialists, to go to the emergency room every time her blood pressure is high, to get annual stress tests and carotid artery screening, and to use the hospital as the preferred place of her care, I as her primary care doctors will be told that I have a poor value score because of her excess consumption of health care. We have no recourse to stop that type of excess, and patients do not pay for it; they have no skin in the game at all, since Medicare is a buffet of health care for most of them. They are in fact encouraged to seek hospital-level care because, under Medicare, it is cheaper and easier for them. But we have to pay the price for their decisions. How does that make sense?
Nothing in Medicare has Changed that will Help Us to Curb Excessive Care. In my book I talk at length about how Medicare eschews home care and encourages aggressive hospital level care. We (and our patients) would often prefer to treat many people at home, and our value grade would certainly improve if we could do that, as would our patients’ outcomes. But although we are told to cut costs, Medicare has not at all altered its central tenant: hospital care is free for patients and it affords patients tremendous benefits that home care does not allow, while home care is costly for patients and very difficult to arrange and manage for doctors. Until this equation is at least altered, how can we as primary care doctors be expected to be rewarded and punished under a system that fights against the very value it seeks to promote? First fix the system, then encourage us to practice efficiently. We can’t be told by Medicare to practice value care when Medicare is simultaneously rewarding doctors/np’s and patients who do just the opposite!
Nothing is being done to Ease the Primary Care Crisis. As mentioned, primary care centered medical care is much more efficient and has better outcomes than specialist centered care. Yet our country is gravitating quickly to the latter, with most doctors now working as specialists, and the vast majority of medical students entering specialty fields. That trend is completely the choice of Medicare. Even while it tosses complicated and often counterproductive carrots and sticks at primary care docs/nps in an effort to promote value, Medicare is dropping its own shortcoming on the backs of primary care doctors by promulgating a specialty-based health care system that is the very antithesis of value. How can Medicare change the ratio of primary care to specialist care? Two very simple ways. First, Medicare, not the free market, determines how much each doctor earns. Under current rules that reward procedures and de-value cerebral medical care, specialists are earning $150,000-$200,000 per year more than primary care doctors on average. The medical school debt for both groups is identical and thus students are flocking to specialty fields. This cavernous pay gap is unlike any other in the world. Physician pay is largely determined by a small cabal in the AMA controlled by specialists that recommends physician payscales to CMS, which Medicare (and then most other private insurers) implement. With a single alteration in that formula, the salaries of primary care docs and specialists can move closer together (something that can be done by the end of the day; it’s that easy!), and we would find far more students gravitating to primary care fields. Second, Medicare essentially pays hospitals to train resident doctors. On average it allots several hundred thousands of dollars per resident to hospitals at a total cost of $10 billion a year! Medicare therefore has the financial authority to tell hospitals that they can only train a certain number of specialists and must use most of that money to train primary care doctors. It is up to hospitals if they want the money or not, but again, overnight, the entire complexion of the medical school landscape would become more primary care focused. This is true value. It would be far more effective than the feckless, time consuming tasks that Medicare is wrapping around our necks as part of MIPS. And it is something that Medicare has not even considered doing.
What else can we be doing to fix the system? In my book I lay out a very simple and inexpensive three tiered plan. First, reward shared decision making; allow doctors and patients to make decisions together, encourage docs/nps to use valid decision tools, and only pay for interventions of dubious efficacy if doctors/nps can demonstrate that they provided patients with accurate data and discussed that data in a patient centered way. Second, make home care as inexpensive and easy to arrange as hospital care. And third, train and appropriately remunerate more primary care doctors. It’s really that simple! We don’t need complex report cards like MIPS is creating to tweak a dysfunctional system. To actually fix the system requires a change in focus: primary care doctors and patients need to be the instruments of reform if we are going to return quality and value to our health care delivery universe.
There are some potentially exciting innovations floating out in Medicare’s atmosphere that do approach true “quality and value” in health care. Some ACO’s, like the one I belong to, are trying to enroll in a program that rewards them for saving money and allows them to be creative in providing care; they can waive the 3 night rule for hospitals, they can provide more home care, they can emphasize primary care, ect. But they expose themselves to risk if the programs do not work, and they are still burdened by Medicare’s quality indicators which, as we have shown, detract from quality and value. Also, Medicare has piloted a home care program called Independence at Home that subsidizes docs/nps who make home visits if they can save the system money. In fact, such programs when done on high risk populations, have saved more than $10,000 per patient per year, and some of that money was redistributed to the actual practices (although likely most of it evaporated due to administrative costs and the lost revenue from seeing fewer patients). Just imagine, though, how much Medicare would save if it created systems where patients could receive hospital level care at home. We talk about that in my blogs and books, but for some reason Medicare has not reached a juncture where it is willing to finance such a sensible and easy to implement step. Likely there are many special interests involved that are obstructing genuine reform like this. But if Medicare wants to achieve actual value, the answers lie not in MIPS, which is a convoluted and punitive system that will accomplish nothing other than driving more primary care doctors out of business, but rather it lies in much more simple approaches that can be implemented without pain or high cost. It’s time that Medicare stops convening with “experts” and starts using common sense. Talk to primary care doctors and patients; we get it! Make your voices known at www.regulations.gov/#!submitComment;D=CMS-2016-0060-0068.