With the ruination of American teaching using “value-based” purchasing and payment concepts virtually complete, the U.S. government is now training its sights on medicine with similar intentions. With the new MACRA pay-for-performance program, CMS bureaucrats believe they can force health care providers to practice better “quality” care by collecting clinical performance, practice-related, and cost data, and basing payment increases and penalties on the results.
There is one big problem associated with such an approach that these bureaucrats are ignoring. When these programs have been studied, they have not been shown to reliably or meaningfully improve the quality of medical care or reduce health care spending. But the government moves forward undeterred by the evidence.
But there are a number of relatively simple reasons why such approaches tend to fail. First of all, it can take a great deal of work just to collect and report so much data, and with medical professionals and support staff already overburdened with administrative tasks, there may not be time or resources to do anything else. The very act of collecting the data becomes the primary focus rather than using the data as a means to improve care. One would think that with the move to electronic health records (EHRs) this would be a non-issue, but that is just not the case. As many EHR users are aware, their use may entail more work, not less.
Even more importantly, though, the broken American health care system is defined by systemic barriers that virtually guarantee poor quality. Lack of health insurance, as well as exorbitant premiums, high deductibles, rising co-pays, incomplete coverage, and the rising costs of medical testing and medications all conspire to deny access for many patients even to the most basic care. Until such issues are addressed, the results of efforts to improve the quality of American health care will be severely limited.
So, here’s a novel idea. Rather than re-hashing this doomed-to-fail “value-based” approach, how about helping physicians to improve performance by providing them more resources in those areas where they need help. Rather than increasing physicians’ administrative burdens, and threatening them with penalties if they fail, decrease those burdens and provide them with specific tools they can access to improve their care. There are a number of areas where I think this would be of great benefit.
Immunizations. Improving immunization rates is one of the simplest and most cost-effective ways to improve health outcomes. However, the expanding number of required vaccines across the age spectrum, and the high costs of vaccines for HPV, meningococcus, herpes zoster, and pneumonia (the Prevnar vaccine can cost close to $200), make the upfront costs of purchasing and administering all of these immunizations (in addition to often poor reimbursement rates) prohibitive for many medical offices. Having individual practices and health systems purchase vaccine inventory, feasible when there were far fewer required vaccines, may no longer be the best approach.
A better approach today might be to have the federal government purchase the vaccines and provide them, free of cost, to medical practices. Practices would continue to receive small fees for administering the vaccines. Such payments, coupled with the absence of any threat of financial losses associated with vaccines, would provide a much better incentive for physicians vaccinate their patients. I would be overjoyed to have such an option available.
Cancer screenings. Another area where American health care tends to fall short is rates of cervical cancer, breast cancer and colon cancer screening. Clearly, individual practices and health systems find it challenging to track, schedule, and perform all of the necessary testing.
But maybe cancer screening rates would be better if this work were performed by some central agency whose sole focus was to organize such testing for all patients. Physicians could access a national cancer screening database to update their own records as necessary.
Once again, I think it would be incredible to have such options available, freeing my staff and me to focus on other aspects of patient care and access issues.
Lifestyle coaching. Poor eating choices, lack of exercise and excessive weight are the underlying causes of the most serious and costly chronic diseases in the U.S. But few physicians or their staff has the time or expertise necessary to meaningfully and effectively intervene to help patients optimize such lifestyle issues. In addition, many regions may lack the necessary number of dieticians, nutritionists and lifestyle coaches. And insurance coverage and patient time limitations may limit access to such things.
But the stakes are so high because the disease burden and the costs associated with these conditions are so great, that having a federal program to train and make available intensive lifestyle coaching services (through in-person or even telehealth appointments) to more patients might be a worthwhile investment in national health. I would love to think that I had such an option available for more of my overweight and chronic diseases patients.
Other areas. There are many such services that we could make available to physician practices that would decrease their burdens and help to improve national health statistics. We could develop nationalized systems to increase access to many specialty medical consultation services that are not well represented in every region of the nation, like diabetes care or mental health professionals. We could standardize and make available high-quality patient educational resources to all patients and clinicians. We could even develop a central source for continuing medical education materials and modules for physicians.
I can only imagine what it would be like to practice in an environment where, rather than facing the threat of being penalized for taking care of the most challenging patients, or for falling short of some goal, if there were services available to help me and my patients do better.
Matthew Hahn is a family physician who blogs at his self-titled site, Matthew Hahn, MD. He is the author of Distracted: How Regulations Are Destroying the Practice of Medicine and Preventing True Health-Care Reform.
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