Dr. Michael Kitchell initially welcomed the federal government’s new quality incentives for doctors. His medical group in Iowa has always scored better than most in the quality reports that Medicare has provided doctors in recent years, he said.
But when the government launched a new payment system that will soon apply to all physicians who accept Medicare, Dr. Kitchell’s McFarland Clinic in Ames didn’t win a bonus. In fact, there are few winners: Out of 1,010 large physician groups that the government evaluated, just 14 are getting payment increases this year, according to Medicare. Losers also are scarce. Only 11 groups will be getting reductions for low quality or high spending.
“We performed well, but not enough for the bonus,” said Dr. Kitchell, a neurologist. “My sense of disappointment here is really significant. Why even bother?”
Within 3 years, the Obama administration wants quality of care to be considered in allocating $9 of every $10 Medicare pays directly to providers to treat the elderly and disabled. One part of that effort is well underway: revising hospital payments based on excess readmissions, patient satisfaction, and other quality measures. Expanding this approach to physicians is touchier, as many are suspicious of the government judging them and reluctant to share performance metrics that Medicare requests.
“Without having any indication that this is improving patient care, they just keep piling on additional requirements,” said Dr. Mark Donnell, an anesthesiologist in Silver City, N.M. Dr. Donnell said he only reports a third of the quality measures he is expected to. “So much of what’s done in medicine is only done to meet the requirements,” he said.
The new financial incentive for doctors, called a physician value-based payment modifier, allows the federal government to boost or lower the amount it reimburses doctors based on how they score on quality measures and how much their patients cost Medicare. How doctors rate this year will determine payments for more than 900,000 physicians by 2017.
Medicare is easing doctors into the program, applying it this year only to medical groups with at least 100 health professionals, including doctors, nurses, speech-language pathologists, and occupational therapists. Next year, the program expands Medicare to groups of 10 or more health professionals. In 2017, all remaining doctors who take Medicare – along with about 360,000 other health professionals – will be included. By early in the next decade, 9% of the payments Medicare makes to doctors and other professionals would be at risk under a bill that the House of Representatives passed in March.
The quality metrics used to judge doctors vary by specialty. One test looks at how consistently doctors keep an accurate list of all the drugs patients were taking. Others track the rate of complications after cataract surgery or whether patients received recommended treatments for particular cancers.
There are more than 250 quality measures. Groups and doctors must report a selection – generally nine, which they choose – or else be automatically penalized. This year, 319 large medical groups are having their reimbursements reduced by 1% because they did not meet Medicare’s reporting standards.
Physicians who do report their quality data fear the measures are sometimes misguided, usually a hassle and may encourage doctors to avoid poorer and sicker patients, who tend to have more trouble controlling asthma or staying on antidepressants, for instance.
Dr. Leanne Chrisman-Khawam, a family physician in Cleveland, said many of her patients have difficulty just getting to follow-up appointments, since they must take two or three buses. She said those battling obesity or diabetes are less likely to reform their diets to emphasize fresh foods, which are expensive and less available in poor neighborhoods. “You’re going to link that physician’s payment to that life?” she asked.
Dr. Hamilton Lempert, an emergency physician in Cincinnati, criticized one measure that requires him to track how often he follows up with patients with high blood pressure.
“Most everyone’s blood pressure is elevated in the emergency department because they’re anxious,” Dr. Lempert said. Another metric encourages testing the heart’s electrical impulses in patients with nontraumatic chest pain, which Lempert said has led emergency rooms to give priority to these cases over more serious ones.
“It’s just very frustrating, the things we have to do to jump through the hoops,” he said.
In the first year that doctors are affected by the program, they can choose to forgo bonuses or penalties based on their performance. After that, the program is mandatory. This year, 564 groups opted out, but even if all of them had been included, only 3% would have gotten increases and 38% would have seen lower payments, mostly for not satisfactorily reporting quality measures, Medicare data show.