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Colleagues,
We recently published an article documenting family physicians' frustrations with the Centers for Medicare & Medicaid Services' documentation, coding, and billing rules we are forced to work under by CMS and private insurance companies. Plenty of stories have mentioned the income disparity between primary care docs and procedural subspecialists. I have never read an article that asked why this disparity even exists in the first place. They talk about salary differences or first salaries out of residency, as if the only factor at play was competitive market forces. No journalist has cracked the code (that I've read) that understands that the root of this discrimination is the CMS billing system, which over 90% of insurance companies use. [Editor's note: this Washington Monthly article explains why Medicare's price-fixing always undervalues the work of primary care physicians.]
I don't understand why non-physicians seem so indifferent to this aspect of our work lives. Their attitude always seems to be some version of "the details of the rules are boring, you're a rich doctor, so quit complaining." These awful rules affect their patient experience. Patients complain about their doctor being rushed and not listening to them. CMS rules often cause us to behave this way.
Richard Young
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I wonder if this group would want to try to submit something to CMS about what we should really measure with patient outcomes like quality of life. Not sure who could take the lead, but having a lot of names on such a document would be a strong statement to them at least.
Hugh Silk
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Be careful what you ask for. The whole quality movement in family medicine has led us astray: it assumes there is one right answer for a medical issue, e.g., antibiotics one hour prior to major surgery. Because of the complexity of what we do, often there is no one right answer, so what do we measure?
The quality improvement (QI) movement is largely unable to risk adjust. If we propose measures for quality of life (QOL) outcomes for constructs such as energy levels, sleep quality, shortness of breath, then we create incentives for family physicians to "dump" the sickest patients, which is exactly the opposite of what this country needs. Up to now, QI has assumed that more is better, which is anti-family medicine. None of the criteria measure things we don't do to patients. The Choosing Wisely campaign offers hope for a more balanced portfolio.
Politicians, regulators, and industria-crats don't want to hear this, but a lot of the value of our services simply can't be measured. Many of our decisions have no evidence base to declare one right answer. To even accept simple disease-specific measures as an overall assessment of care quality implies that our decisions are simple and straightforward, when nothing could be further from the truth.
This is not to say that physicians and their practices should not reflect on their own performance and measure internal processes to improve local care delivery systems. There is value to performance improvement, just not as a summative evaluation of a physician or practice. So let's all sign a document that tells CMS to abandon the folly of measuring family physician quality with simplistic electronic medical record- or billing-based measures. Our worlds are too complex for the computers to keep up with.
Richard Young
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Richard Young
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I wonder if this group would want to try to submit something to CMS about what we should really measure with patient outcomes like quality of life. Not sure who could take the lead, but having a lot of names on such a document would be a strong statement to them at least.
Hugh Silk
--
Be careful what you ask for. The whole quality movement in family medicine has led us astray: it assumes there is one right answer for a medical issue, e.g., antibiotics one hour prior to major surgery. Because of the complexity of what we do, often there is no one right answer, so what do we measure?
The quality improvement (QI) movement is largely unable to risk adjust. If we propose measures for quality of life (QOL) outcomes for constructs such as energy levels, sleep quality, shortness of breath, then we create incentives for family physicians to "dump" the sickest patients, which is exactly the opposite of what this country needs. Up to now, QI has assumed that more is better, which is anti-family medicine. None of the criteria measure things we don't do to patients. The Choosing Wisely campaign offers hope for a more balanced portfolio.
Politicians, regulators, and industria-crats don't want to hear this, but a lot of the value of our services simply can't be measured. Many of our decisions have no evidence base to declare one right answer. To even accept simple disease-specific measures as an overall assessment of care quality implies that our decisions are simple and straightforward, when nothing could be further from the truth.
This is not to say that physicians and their practices should not reflect on their own performance and measure internal processes to improve local care delivery systems. There is value to performance improvement, just not as a summative evaluation of a physician or practice. So let's all sign a document that tells CMS to abandon the folly of measuring family physician quality with simplistic electronic medical record- or billing-based measures. Our worlds are too complex for the computers to keep up with.
Richard Young
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I agree what we do is very, very subjective. But the alternative is to wait to see what they decide on and be forced to practice that way. Someone, somewhere is going to hold us to something; we should decide what that is. Maybe it is relationships. Maybe it is intent to change behavior. Maybe it is QOL but with wiggle room - a movement of QOL in the right direction counts as much as better QOL.
This is the kind of conversation we need where we offer something that we think we could be measured by, not just what we don't want to be measured by.
Hugh Silk
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Submit to, or occupy CMS? Only the latter will have any meaningful impact.
Michael Fine
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I think this is a challenge for the Family Medicine community. We have a talented core group of researchers who understand both quantitative and qualitative measurement methods. Also, Direct Primary Care can remove the control of those who juggle the carrots and place the measurement that matters in the hands of the patient.
Larry Bauer
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I will be attending a symposium in about two weeks to talk about future research directions concerning behavioral change. One of the most important things we do in family medicine is to help patients make decisions around, and commitments toward, change. What can we measure that makes a difference? What is it about family medicine that helps patients in that process?
David Loxterkamp
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David, this probably comes as no surprise, but I disagree with your "most important things" statement. The most important thing we do is not to cause patients to change their behavior, but to non-judgmentally accept them as they are and to foster a lifelong conversation with them about their options and trade-offs for every health-related concern they have. How much impact do we have on causing smokers to quit long-term? About 5%. How much do we affect weight loss? Essentially none at all. We should tell our patients to go to Weight Watchers and not waste their time or society’s resources trying to "educate" them into lower weights. These outcomes are not what is so valuable about family physicians.
This is another example of why industrial QI thinking doesn’t work for much of family medicine. QI assumes there is a discrete outcome that can be declared as success or failure within a relatively short time frame: over a few Plan, Do, Study, Act cycles. One of the ways we deliver better care at a lower cost is to foster an endless series of negotiations with patients over a lifetime, constantly adjusting the options and goals as the natural history of the disease evolves and all of the other changes in their lives affect their health: births, deaths, job loss, job gain, bouts of depression, bouts of elation, and everything in between.
This is the message CMS needs to hear. Maybe a measure about how much time your family physician talked to you about your options would be valid. Of course, this shouldn’t be measured until CMS agrees to pay us to take the time to implement it.
Richard Young
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Richard, as a patient who wants a doctor to work WITH, not to be harangued by, your point is spot on. I love my family doctor because he assumes I am an intelligent individual who wants to be healthy and live a happy long life -- not a bag of organs in need of fixing.
Shannon Brownlee
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Friends, this is an interesting series of comments. I've noticed after about 177,000 patient encounters many similarities and differences. One of my responsibilities as a Family Physician is to make sure that each patient knows that he or she matters - sort of a human validation and often a role validation (father, mother, patient, guardian, etc.). AND, know that I matter, too.
Could we have a measurable energy that when combined with our context and the patient's context, delivers wholeness? The human energy field of patient and physician engaged in dyadic sharing and mutual interdependence may be measurable as technology evolves (probably with a cell phone). Their fear of short or long term loss, or that we won't connect to their reality and further mis-align them with their potential, combined with our fear that their problem might exceed our skills or our coding skills or our employer's mandates for our scope of practice and time allotment may suddenly (or over time) melt into a mutually beneficial human dance of meaning, enhancing organ and system and spiritual unction for both. Can the creative tension of this dyadic dance show merit of a financial sort to someone who might pay?
I love what I get to do. I love being a Family Physician. I'm blessed to get a close look at the human condition in the context of meaningful relationships that enable humans to better align with their values, goals and dreams. And measurable or not, my values, goals and dreams are included in the outcomes of doing Family Medicine.
Pat Jonas
