The unintended consequences of boilerplate guidelines

I recently saw a 90-year old patient in my cardiology office practice. She was demented, but cooperative with the exam. A devoted daughter, with whom she lives, accompanied her to the appointment. Her dementia was severe enough to make a cogent history from the patient impossible. However, the daughter had something on her mind, and it had nothing to do with her mother’s heart condition.

“My mother’s primary care doctor wants her to have a mammogram and colonoscopy. I don’t feel good about this. What’s your opinion?” She asked

“Is she having a problem with her bowels or her breasts?” I responded.

“No,” She replied. “She just says it needs to be done.”

At this point in such a discussion I usually remain neutral, not wanting to second-guess the recommendation of a colleague. However, this seemed so blatantly ridiculous, that I could not hold my tongue.

“Well,” I started, “If it were my mother, I would not consent to those tests.”

The daughter seemed satisfied with that answer, confirming her intuition and already made decision.

After the appointment, I looked at the name of the patient’s primary care doc and insurance. I knew the doctor well, but saw few of her patients, as she belonged to a Medicare replacement HMO that referred rarely to our group. Having known this HMO for years, I was not particularly fond of its track record for providing high quality care. I was even more surprised when days later I read one of their ads in a local newspaper, during the yearly enrollment period for new Medicare Advantage subscribers, and they were bragging they had received a 4.5 (our of 5) star rating from Medicare. Hmmm.

Immediately, I knew that this must have something to do with money. As it turns out, that suspicion was correct. Medicare has started rating its Medicare Advantage plans with 1-5 stars, awarded based upon various factors, such as “improving or maintaining health.” Preventive measures like flu shots, mammograms, and screening colonoscopies are included. What apparently isn’t included in the target measures of quality, is any age cut off. There is absolutely no evidence that these tests improve, or extend, the life of a nonagenarian. Indeed, doing these tests in this setting, is not only a waste of money, but potentially dangerous.

The more stars the HMO gets, the more money they get from Medicare. In fact, this system was part of the ACA passed in 2008. The health plan can garner millions of extra dollars and reward their docs as well. Bingo. Now I understand.

To be clear, I have nothing against preventive medicine. However, this is a classic example of how government mandated rewards for following boilerplate guidelines misses the mark and leads to unintended consequences. Pay for performance is an increasingly popular, yet largely unproven, concept for rewarding the providers of health care. Also known as P4P, this payment model rewards physicians, hospitals, medical groups, and other healthcare providers for meeting certain performance measures for quality and efficiency. Depending upon how they are used, practice guidelines can be helpful or harmful. Based upon their track records, forgive my skepticism when they are placed in the hands of bureaucrats, masters of public health, and politicians.

Writing in his blog for the National Center for Policy Analysis in 2011, John C. Goodman gives a sobering view of how the P4P policy is still unproven:

We examined the effects in 260 hospitals of a pay-for-performance demonstration project carried out by the Centers for Medicare and Medicaid Services in partnership with Premier Inc., a nationwide hospital system. We compared these results to those of a control group of 780 hospitals not in the demonstration project. The performance of the hospitals in the project initially improved more than the performance of the control group: More than half of the pay-for-performance hospitals achieved high performance scores, compared to fewer than a third of the control hospitals. However, after five years, the two groups’ scores were virtually identical.

For better or worse, with ACA now the law of the land, I suspect we will see more of these types of good intentioned guidelines resulting in little improvement in the overall health of the elderly.

David Mokotoff is a cardiologist who blogs at Cardio Author Doc.  He is the author of The Moose’s Children: A Memoir of Betrayal, Death, and Survival.

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  • Henry Ehrlich

    I have great sympathy for the point of view expressed here. However, let’s not pretend that absurd geriatric medical practice began with ACA. I was in a comparable position with two elderly parents for six years that ended mercifully in 2008 and 2009 and there was no shortage of expensive and misdirected medicine directed at them. How many times did I drive to an emergency room 40 miles away in the middle of the night to quash an MRI or CAT scan that would by the doctor’s own admission would have revealed nothing for which my parents could be treated? One of these days after the ACA is more fully implemented, we will have a fuller discussion of how it works that will include, I can only hope, the kind of end-of-life conversations that were precluded by talk of “death panels.”

  • Margaret Polaneczky, MD

    Agree overall that quality is best measured on an individual basis, and screening decisions should be individualized, especially as patients get older.

    However, I thought you and your readers should be aware that Medicare’s quality measure for mammogram only applies to women ages 40-69.
    “Percentage of women aged 40 through 69 years who had a mammogram to screen for breast cancer within 24 months.”

    Therefore, not referring a 90 yo’s for a mammogram would not impact that HMO’s medicare quality rating.

    The problem may not be the guidelines themselves but those who misinterpret and misapply them. An unintended consequence indeed.

    • kjindal

      what about when the medicare advantage plan wants me to put my former patient on an ACE inhibitor, because he had diabetes, before he died 3 yrs ago.

      • Jonathan Weinkle

        Perhaps you should talk with the oncologists from the old joke – you know the ones, who went down to the morgue to see if just one more round of chemo could turn the tide for Mrs. Smith, only to find a sign on her cooler, left by the nephrologist, saying, “Gone to dialysis.”

  • Gaspere (Gus) Geraci

    Guidelines created with reality in mind include exceptions or limits, like the ages given below. There are always exceptions that are correct and just. No one ever expects 100% compliance – because exceptions will always justifiably exist. Misinterpretation of the guidelines occurs, and if anyone tells you your goal is 100%, that is always a bad guideline. Don’t fell offended when you get a report showing a patient is out of compliance. Feel offended when you can’t give feedback about why they shouldn’t be expected to be in compliance, or just accept that your legitimate reason is legitimate, and work on those who don’t have a legitimate reason.

  • Jonathan Weinkle

    ACA passed in 2010, for what it’s worth, not 2008. And the absence of any age cutoff is mind-boggling, since current guidelines for all of the tests mentioned have upper age limits or suggested points at which the harms outweigh the benefits (mammography probably most murky). As a PCP myself, I am probably more likely to be the one nixing the test – Pap smear for a woman in her 70s, colonoscopy for a healthy 85 year old man.

  • drjoekosterich

    Needless tests lead to needless treatment. Indeed it is almost certain more harm will be done than good. The stupidity of government and insurance protocols knows no bounds

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