Blog | Friday, August 28, 2015

Are we really ready for quality-based doctor payments?


The dramatic change in how we pay doctors is well underway. The “fee-for-service” model, in which you get paid for every “thing” you do, is on the way out. Under this model, for example, I can get paid about $60 for helping someone manage their heart disease and diabetes, thereby preventing severe complications. If I simply clean out their ears, I can bill closer to $80 because it's a “procedure.”

Under the newer “quality-based” model, more of my payment is based on outcomes: what percentage of my diabetics have their sugar under control, etc. This noble idea has a number of inherent problems that have been addressed elsewhere, but one of the biggest is bureaucratic.

Every insurer has its own quality measures and reporting schemes. Some companies have several, depending on the insurance product. For example, Blue Cross collects data 1 way for Medicare patients, another way for HMO patients, and other ways for plans purchased by employers.

We have no idea how to keep track of all of these reporting systems. There seems to be an endless supply of data that they request, some relevant, some not, and some insane.

For example, for some of my BCBS patients I have to log in to their website and enter patient data. Among the data is a question asking if the patient has a history of depression. If I answer “yes” it asks for a depression “score” based on a simple clinical tool. Since my patient isn't currently depressed, I enter a score of 0, and get rejected. You're not allowed to have been depressed in the past, but no longer be depressed. When I've questioned BCBS about it their response is often either nonsensical or they tell me to lie. Really; they told me more than once to just answer that the patient has no history of depression.

And that's just for one group of BCBS patients. Others may not require this sort of reporting but another log-on adventure entirely.

It is nearly impossible for me to figure out which of these so-called incentive programs cost me money or make me money or are simply a wash. I cannot for the life of me figure out exactly how many different programs there are and how to satisfy their requirements.

If reimbursing doctors for quality of care is truly the goal (rather than the cynical interpretation of it being a way to avoid paying docs via Byzantine reporting requirements) then we need one system. If we had a single-payer system this would be fairly simple, but since we don't, there should be a data repository that all the insurers fund and are required to use. This way, doctors wouldn't have to take time out of the exam room to try to fulfill each set of requirements, or worse, give up entirely.

It is hard to overstate the amount of time taken gathering and reporting this data. Take, for example, colon cancer screening. Because it may have occurred a couple of years ago (and is still up to date) it may not appear in the insurance company's billing records and therefore is listed as “incomplete”. Then we have to review “x” number of charts, looking for records, dates, etc. And if the patient has changed insurers or doctors a few times, there may be no data at all to work with.

At this point, quality-based reimbursement is a Kafkaesque joke. Doctors will lose money, patients will lose time with their doctors, and quality will suffer as doctors spend more time trying to figure out how to report data than how to treat disease.