Monday, December 16, 2013

Skepticism about Value-Based Physician Payments

The civilized man has the moral obligation to be skeptical, to demand credentials of all statements that claim to be facts.

Bergan Evans (1904-1978), The Natural History of Nonsense, XIV

I am skeptical about two ACA-related federal programs – PVBM (Physician Value Based Payment Modifier) and PQRS (Physician Quality Reporting System).

Both are designed to reward or punish physicians for delivering high-value low-cost care.   The response among physicians has been dismal, with less that 30% of physicians participating ,  either because of the time, expense, and hassle of entering data,  the meager financial  reward or punishment  (1-2%),  or the feeling that the programs are meaningless.

I am skeptical of those who would have us believe you can measure physician performance and reward them accordingly.  I am skeptical you can measure a physician’s value across the clinical spectrum.    I am skeptical you separate “volume,” i.e., the number of patients seen,  tests ordered , and procedures performed,  from the “value,” i.e.” quality” of the physician.

I agree with this statement in the November 28 New England Journal of Medicine by Robert Berenson, MD, of the Urban Institute and Deborah Kaye of Johns Hopkins,

“ Although we agree the value-based payment is appropriate as a concept, the practical reality is that the Centers for Medicare and Medicaid (CMS), despite heroic efforts, cannot accurately measure any physician’s  overall value,  now or in the foreseeable future.”

You can measure costs.  You can measure fees-for-service.  You can measure numbers of patients seen, tests ordered, procedures done, and to a lesser extent, you can measure outcomes.   But you cannot measure  “value” or “quality,” which are in the eyes of beholder.

Why not?   Part of the problem resides in the complexity of the physician-patient encounters  and complexity of medicine itself.  The typical primary care physicians 400 or more different clinical conditions each year, including  many patients with multiple chronic illnesses.    The variation between patients is enormous,  as is the variety of patient-doctor interactions.  You are dealing with a moving system with multiple moving parts over varying periods of time.   You are dealing with physicians with different clinical approaches,  different listening styles,   different personalities , different clinical reasoning, and different levels of empathy.   You are dealing with patients who have different physician expectations, and who expect or demand different physician skills.

To complicate matters, as a physician you see only  patient at a time,  at different intervals of time,  for different episodes of illness with different levels of severity,  with outcomes over which he or she has little of no control once the patient leaves the hospital or office.  Will patients change their life-long  habits,     will they change their eating habits, will they exercise, will they take their medicines?

Small wonder that physicians do not respect quality or value measures imposed from above.  Small wonder that  physicians willingly accept a 1-2% penalty for not participating in programs that measure only a fraction of what they do. 

You simply cannot measure, much less manage,  most complex clinical  situations, of the creativity and skills required to resolve or alleviate these situations.

Tweet:   Federal programs to measure physicians’  overall value through the use of data are destined to fail,  now and in the foreseeable future.

Sources:  A.T. Chien and M.B. Rosenthal, “Medicare’s Physician Value-Based Payment Modifier – Will the Tectonic Shift Create Waves?”:    R.A. Berenson and D.R. Kaye, “Grading a Physician’s Value -  The Misapplication of Performance Measurement,”  both in November 28 issue of New England Journal of Medicine.

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