Unintended Consequences

Author: Michael Wasserman MD

Originally published: Tuesday, August 30, 2016

How does it feel knowing the clinical decisions our physicians make affect their pocketbook? MIPS, or the Merit-based Incentive Payment System, is now the law of the land. MIPS attempts to incentivize physicians based on quality measures, use of electronic health records, practice improvement approaches and cost of care. The Centers for Medicare and Medicaid (CMS), is tasked with working out the details of the program, which aims to take us from a system where physicians are incentivized to “do something” to patients to one in which “quality” is the predominate goal.

Here’s my quandary: As a Geriatrician, I have practiced a lower cost approach to care my whole career. I try to avoid acute hospitalization, medications and procedures in my frail older patients. Why? Because my experience, as well as a growing body of evidence-based literature, supports this approach. I should be wholeheartedly embracing this new approach to physician incentives. So, why do I feel sick when I think about it?

I am a professional. I have one task, and that is to care for my patients. My patients are human beings and as a Geriatrician my focus is on maximizing their quality of life and function. My patients are not commodities. It is not up to me to determine whether an individual patient costs the health care system more or less. I worry that when the cost of my patient’s care finds its way into my decision making process, my ability to maintain a purely professional relationship with that patient could suffer. Am I being naive? Perhaps. Am I being realistic? Definitely!

We are at an important crossroads when it comes to our healthcare system. Forty-one percent of every Medicare dollar is spent on hospitals. Sixteen percent is spent on pharmaceuticals. Eleven percent is spent on skilled nursing and home health care. Only about five percent is spent compensating primary care physicians. The MIPS program is structured to produce up to 9% bonuses or penalties to physicians. This complicated incentive system has been legislated to be cost neutral when it comes to physician reimbursement. This means that MIPS will penalize a significant portion of primary care physicians because the program has to be a zero-sum game. It is quite possible that primary care physicians whose quality improves will be penalized, despite the fact that their improvement could be saving money in other parts of the health care system. This is one reason that I continue to feel deeply troubled.

Where does the consumer fit into all of this? Do consumers want a physician who is penalized when they cost the system excess dollars, or receives a bonus when they save money? Do they want a physician who will stay in the office after 5 pm in order to avoid sending them to the emergency room? Do they want a physician who will fight to get them an expensive test or medication because it’s the right thing to do? Do patients want to be part of a health care reimbursement game? I worry that we have not taken the time to make sure that consumers understand and have adequately weighed in on this issue.

Everyone harkens back to the days of the old fashioned doctor. I worry that those days are gone. A Medicare patient’s visit to their primary care physician today is typically “three prescriptions, two referrals and a cloud of dust.” If primary care physicians continue this mode of practice, they are not going to get much sympathy from the consumer. Meanwhile, the kind of physician who can provide the kind of care they truly want and need is rapidly becoming extinct.

While the MIPS program is a well-intended approach to this problem, the potential for unintended consequences frightens the hell out of me.

There is definitely an alternative available, but it will require additional legislation to amend MIPS. We should definitely not penalize physicians if they are demonstrating improvement. We cannot afford to hang a cloud of possible penalties over primary care physicians who are already struggling financially. In fact, we need to double down on the concept of promoting and supporting high quality primary care. There is clearly evidence that intensive coordinated primary care models of care can lead to a significant reduction in costs that are due to hospitalization and emergency department visits. A twenty percent increase in what we expend on primary care reimbursement would only amount to a 1% increase in Medicare expenditures! We would only have to reduce hospital and pharmaceutical costs by less than 2% in order for this to bring about a positive return on investment (ROI). My experience in such care models suggests a much higher impact on these costs, and hence a much higher ROI. Let’s avoid the unintended consequences of the existing MIPS program. Looking at the program from the consumer’s perspective will force us to develop approaches that help both primary care physicians and patients.