Should Doctors Get Paid Less If They Don’t Keep Patients Healthy?

One important piece of health policy where Republicans and Democrats agree


At the moment, the political parties seem to disagree on almost everything healthcare-related. There’s one major piece of health policy, though, on which they do agree: Both want to change how Medicare, the country’s largest insurer, pays doctors.

Lawmakers as conservative as Utah Republican Sen. Orrin Hatch and as liberal as Michigan Democrat Rep. Sandy Levin are meeting to consider a proposal that would change the way physicians get paid. Rather than the current system, which pays doctors for every test or procedure they do, the new method would pay physicians based on whether they help patients get or stay healthy.

Under the proposed system, health professionals billing Medicare would be scored on several measures, including whether they use electronic health records and if they try to keep patients healthy after they leave the office. Doctors with the highest aggregate score would get a bonus payment; those with the lowest scores would see their payments slashed. The message the federal government would be trying to get across is clear: Improve your care or pay the price.

The catch? Congress might agree to change payments, but doctors may not care to adopt them. As Robert Berenson, an internist who has held numerous Medicare policy positions in the government, pointed out last month, less than 30 percent of Medicare doctors have submitted data in the federal government’s current effort to get doctors to track quality measures. The low participation rate signals that something is amiss.

Take a look at Houston, where Medicare patients are a big business. Medicare spent $11,567 on each enrollee in the Houston area in 2010, according to the Dartmouth Atlas, putting it well ahead of the national average of $9,584.

It’s also the city where John McCarthy has practiced hematology for nearly three decades. Or, as he is known to me, Uncle John. He was the first person I reached out to on this topic because he always loves a good, heated health care debate.

"Quality and quantity metrics are business speak, this pseudonymous lingo that is being used to talk about rationing. Some of it is good, but a lot of it is hocus pocus," he told me almost immediately when I called him. Doctors, for the most part, he argues, have always used the best evidence for treating their patients.

“We take vital signs every time a patient comes in to our office. Now we have to report them to the government. But in 90 percent of my patients, their blood pressure issues are managed by other doctors, such as their primary care physician or a cardiologist. But we still have to record it, even though it doesn’t measure the quality of my assessment of the patients’ blood disorder. So we spend a little time on every patient checking off boxes that are simply misused or misunderstood by the government,” McCarthy said.

And that time adds up. A 2013 Medscape survey of more than 20,000 physicians found that 51 percent spent 5 to 14 hours per week on paperwork. That figure was up from 23 percent in 2012.

McCarthy points to a quality measure used within his own field, backed by the federal government, that he believes is not in his patients’ best interest. Whenever a patient presents with a certain type of low blood count, it is now a recommended government quality measure to order a bone marrow test. But McCarthy says he and other hematologists can often tell that it’s too early to do this test, making it simply unnecessary.

“It’s not going to kill people to do bone marrow tests. In fact it makes money for me. It’s not the worst thing in the world, it’s incredibly safe,” says McCarthy. “But if we do one for a mildly normal blood count, we just end up having to do it again later when any treatment is necessary. That is requiring two bone marrow tests where one would do. It’s a hardship on patients.”

In the end, McCarthy is not opposed to all metrics. He just doesn’t have much faith that the government can get them right. His longtime friend, internist Christopher Robben, is more of a believer.

Robben is the chief quality officer for a physician group with more than 300 doctors of various specialties in Houston.

Tracking health metrics is something he’s had a longstanding interest in. Robben was creating Excel spreadsheets in the 1990s to track how his patients with chronic illnesses responded to different treatments. He is actively working with his group now to implement the existing federal quality tracking programs. And Robben is a fan of Donald Berwick, the former Centers for Medicare and Medicaid Services administrator who somewhat of a modern-day Moses of the quality health metrics movement.

“Sometimes we get in the forest and can’t see anything for the trees. If you see a patient with a cough or stomach pain, you can get distracted and you don’t look at the chronic illness. [Quality metrics] hopefully force us to do that,” Robben said in a phone interview. He emphasized that his role as an internist makes quality all the more important, as primary care physicians are the “main engine” of quality.

But even Robben says it is incredibly hard to get quality tracking right. His main concern? Accounting for patients that see more than one doctor in his practice.

“Traditionally, they way doctors were paid encourages overutilization,” Robben said. “I think it’s good to get away from that, if it can be worked out.  But it is so hard to do something like that. It’s so complicated.”