We’ve taken care of Jane and her son, Sam, for a long time (the names are fictitious, but the rest of the story is true, and the real patient approved this story, in case you were wondering). At first, the focus was Sam, with typical well and sick visits. He was one of the sweetest kids we knew.
Sam also had a very significant learning disability. At one point I asked Jane if she wanted any special evaluation or services for Sam beyond what his school was providing. She declined, saying she just loved him the way he was.
Unfortunately, as Sam got older, he got picked on viciously. He became quite depressed. We treated his depression, in addition to his increasingly frequent bouts of stomach and throat pain. Extensive evaluations revealed no significant cause of his complaints. He had developed a classic case of somatization — his very real symptoms were an expression of his emotional pain. It was a sad thing to see such a sweet and happy child become such a pained young man.
Jane’s husband was out of work for a time, and as a result, Jane and Sam lost their health insurance. After a while, Sam was able to get Medicaid coverage. But his Medicaid insurer did not allow Sam to see us because we were out of state (we were half a mile over the state line). At Jane’s request, we saw him anyway, many times for free. We had developed a bond over the years which we knew had an important impact on Sam’s care. It was just the right thing to do.
More recently, Jane has been the focus of our concern. Jane has type 2 diabetes. When they lost their health insurance, Jane stopped coming to see us. When her husband was able to find work, and eventually get insurance, their medications were still too expensive. Jane was unable to afford her insulin. She stayed away from our practice for two years because she didn’t see the point of coming in when she wasn’t really being treated.
My nurse is a true angel to such patients (as are all my staff). She helped Jane fill out complicated pharmacy assistance program papers, and Jane was able to get her insulin again. We also get her samples when we can. We are a tiny, very busy practice, so finding and taking the time to do something like this is not at all easy.
She came back in just recently, and we were able to get some labs. Previously she had been unable to afford even basic blood testing. Her hemoglobin A1c (the test used to monitor diabetes care) was very high, over eleven (we typically try to keep this number near 7).
We increased Jane’s insulin dose, and I asked Jane to call with her results every few days so that we could adjust her insulin dose until her glucose levels improved. She didn’t call back. She did come for a follow-up appointment the next month. I asked why she hadn’t called. She sheepishly informed me that she didn’t have a phone.
So, what does my practice get for all of our special efforts to take care of Jane and her family? As I said, it certainly isn’t money. We have provided a good deal of uncompensated care. We do certainly get the satisfaction of knowing that we are helping someone we care about and who can truly use our help.
What we get from Medicare’s new MACRA “value-based payment” program is a penalty! That’s right. As part of MACRA, we submit clinical quality data, and we will receive either a pay increase or a penalty in the future depending on our results. One such clinical quality measure focuses on diabetes care. We are assessed for how many patients’ diabetes is out of control, determined by a hemoglobin A1c over nine. As I said, Jane’s number is over eleven. So, for our efforts trying to do the nearly impossible, against the odds, to try and help Jane, the government will penalize us. Not help us. Not give us (or Jane) more resources. Penalize us.
So, “value-based pay,” as it is currently defined by this new MACRA program, penalizes us for our best efforts. It makes us responsible for American society’s (and our government’s) ills and weaknesses, over which we have no control. It is a stupid way to do things, and it should be stopped now.
I am beyond angry about this. A payment system that includes penalties in a health care environment where we are unable to get even basic care for our patients is a bad idea. It is another example that demonstrates how misguided our data — and control-obsessed government bureaucracy has become. Rather than encourage better care, it encourages physicians to avoid the sickest and poorest patients, the people who we want to help the most.
Matthew Hahn is a family physician who blogs at his self-titled site, Matthew Hahn, MD.
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