Physician quality ratings

[scrub-jay]

Kris, that sounds more like the provision for increasing the use of bundled payments, not the quality improvement provisions. Although related, that one is another one that is flying under the radar and has the potential to really change the surgical and anesthesiology fields, dramatically.

[mommax3]

Somewhat of a tangent....

This is how teacher pay in Indiana (and some other states, too) is being calculated now. It is based on student performance on tests and on student growth over the course of a year. Of course teachers want all their students to perform well on tests and show academic growth, just as docs want to see their patients become (or remain) healthy. But rewarding or penalizing any professional for outcomes when many of the things factoring into that outcome are beyond their control is wrong.....and teachers can't "fire" students!

[scrub-jay]

Somewhat of a tangent....

This is how teacher pay in Indiana (and some other states, too) is being calculated now. It is based on student performance on tests and on student growth over the course of a year. Of course teachers want all their students to perform well on tests and show academic growth, just as docs want to see their patients become (or remain) healthy. But rewarding or penalizing any professional for outcomes when many of the things factoring into that outcome are beyond their control is wrong.....and teachers can't "fire" students!

Is this part of "no child left behind" ??

[PrincessFiona]

Not a tangent, Sally ... I was talking with a friend of mine who teaches in the Dallas schools about this recently. They are graded based on student performance so none of them want the difficult kids (of course). In her district, the kids that schmooze the principal and belong to the *in crowd* of teachers (that's how she put it, not me!) managed to keep the kids who were doing well while others got saddled with children with learning issues or low scores.

My friend teaches in a special program for immigrants of mexicans. Her job is to teach in half spanish/half english to help the kids get up to speed while they slowly learn english. Her students historically do poorly on these exams because of the language barrier and the social issues they face. She said many of them come to school without having had breakfast, without clean clothes etc. Much of her day is spent meeting their basic needs.

She is such a great teacher, but she is applying outside of the state of TX now.

There is so much crazy in the US lately...

Kris

[Sheherezade]

What I understand is that medicare? now offers or will offer a one time fee for a particular surgical procedure. This must be divided up between surgeon and anesthesiologist. If all goes swimmingly, awesome. If not? Any additional money comes out of the pockets of the surgeons. So low risk patients are better, obviously ... but if your low risk patient has a complication (infection, etc) you pay for the subsequent treatment out of your money until it's all used up.

This is the part that has my DH all in a tizzy. He operates on extremely complex cancer patients - often with multiple issues. However, he (and the hospital frankly) are wondering if they will be able to offer these patients surgery if the payment is done in this manner. Since my husband usually takes on the hard luck cases that are turned away by his partners who prefer patients with a low risk of any complications, he's kind of shocked that he may eventually be telling these people that no one can help them. And with cancer, that is telling them that they will not survive where in the past, they would have. They would have multiple complications (blood clots, bowel obstructions) that a healthier individual with the same cancer - or maybe a differently shaped tumor - wouldn't experience - but they do survive. Their cancer is just more costly to treat even though it's still "ovarian cancer" or "cervical cancer".

If the hospital decides that it isn't worth the lost income for cases that are harder to do, they won't be done at all. Most cancer patients are on Medicare, so it's a big problem.

[Sheherezade]

There is so much crazy in the US lately...

Word.

[scrub-jay]

If anyone wants to know more about the bundled payments, from Healthcare.gov:

Expanded Authority to Bundle Payments

Effective no later than January 1, 2013.
The law establishes a national pilot program to encourage hospitals, doctors, and other providers to work together to improve the coordination and quality of patient care. Under payment “bundling,” hospitals, doctors, and providers are paid a flat rate for an episode of care rather than the current fragmented system where each service or test or bundles of items or services are billed separately to Medicare. For example, instead of a surgical procedure generating multiple claims from multiple providers, the entire team is compensated with a “bundled” payment that provides incentives to deliver health care services more efficiently while maintaining or improving quality of care. It aligns the incentives of those delivering care, and savings are shared between providers and the Medicare program.

Huge huge potential impacts.

[SoonerTexan]

He operates on extremely complex cancer patients - often with multiple issues.

How do you even judge oncologists on "positive outcomes?"

[mommax3]

This is the part that has my DH all in a tizzy. He operates on extremely complex cancer patients - often with multiple issues. However, he (and the hospital frankly) are wondering if they will be able to offer these patients surgery if the payment is done in this manner. Since my husband usually takes on the hard luck cases that are turned away by his partners who prefer patients with a low risk of any complications, he's kind of shocked that he may eventually be telling these people that no one can help them. And with cancer, that is telling them that they will not survive where in the past, they would have. They would have multiple complications (blood clots, bowel obstructions) that a healthier individual with the same cancer - or maybe a differently shaped tumor - wouldn't experience - but they do survive. Their cancer is just more costly to treat even though it's still "ovarian cancer" or "cervical cancer".

If the hospital decides that it isn't worth the lost income for cases that are harder to do, they won't be done at all. Most cancer patients are on Medicare, so it's a big problem.

I am no Sarah Palin fan, but in effect, isn't this the "death panel" she was so maligned for referencing?

[PrincessFiona]

At the end of the day, it will reflect poorly on *money-hungry* physicians who will be pressured to see these cases and take a serious pay cut either way is my guess.

I think this is a lose-lose for doctors and patients. :/

[mommax3]

I don't think doctors will be pressured to take the kind of cases Angie described, honestly, because it isn't *only* the doctors that would have to eat the associated costs....it would be the hospitals, too.

[PrincessFiona]

I agree Sally ... I'm talking about it from the perspective of the patient who doesn't understand the politics/economics of the situation.

DH works at a hospital with the largest number of inpatient mental health beds in the state ... because it's a Catholic hospital, they eat the costs. Inpatient mental health is a financial loser. What happens when it becomes such a numbers game that even this hospital turns people away? Scary.

[Phoebe]

Somewhat of a tangent....

This is how teacher pay in Indiana (and some other states, too) is being calculated now. It is based on student performance on tests and on student growth over the course of a year. Of course teachers want all their students to perform well on tests and show academic growth, just as docs want to see their patients become (or remain) healthy. But rewarding or penalizing any professional for outcomes when many of the things factoring into that outcome are beyond their control is wrong.....and teachers can't "fire" students!

Don't even get me started! Our school had a handful of their best teachers retire because of this change. It promotes competition between teachers.

[Liisi]

My SO and I talk about these issues a lot. She gives great, impassioned speeches on the topic (to me!). It's really crazy, I think. I understand the reasoning behind it - if physicians' pay is only tied to the quantity of patients they see, that's no good - what's the point of a doctor's pay increasing when s/he sees 8 patients in an hour, if s/he's providing crappy care to those 8 patients?? So I'm glad there's an acknowledgment that quality is important, too. But the way quality is being measured is not quite right. As my SO says, patient satisfaction should count for a hell of a lot. Quality = a patient feeling like they're being heard/listened to, feeling like they have enough time with their doctor to have all of their needs addressed, feeling like they have a doctor they can trust and be honest with, and feeling like the doctor is helping them improve their health. Measuring quality solely by patient outcomes does not work. There are so many factors physicians don't have control over, such as patients' compliance and/or willingness to try/change, and many factors neither physician nor patient have control over, such as the way patients' socio-economic status affects their health, environmental factors that affect health, etc. The new system just really makes no sense to me. If one doctor's patient panel is full of mostly healthy people who live in an affluent community with access to things like personal trainers, farmer's markets and health food stores, clean air and water, and money for all healthcare supplies, of course there will be better outcomes for those patients - as opposed to a doctor who has a panel mostly full of people who live in a poor community, near several chemical-spewing factories and landfills, with nothing but fast food restaurants and convenience stores, and work 3 jobs and have no time to exercise and no money for healthcare supplies. If anything, doctors should get paid MORE to help the disadvantaged, most unwell patients, not be penalized by all of these barriers to health that are out of their control.

And yes, as soon as I heard about this, it immediately reminded me of the No Child Left Behind Act. It's so wrong that teachers have to teach to the test, instead of being allowed to use their creativity and talents to create a curriculum for their students that is interesting, relevant, varied, designed to meet the needs of the whole child, and tailored to each child's unique strengths, interests, and needs. It's so wrong that there is ONE set of educational standards that ALL children must meet, regardless of whether a student has diagnosed special needs, and regardless of the nature or degree of those special needs. It's like the Albert Einstein quote - “If you judge a fish on its ability to climb a tree, it will forever think it’s stupid.” Teachers and schools get punished for students' low scores on the stupid, one-size-fits-all test, but it's the test/measurements themselves that are the problem, not the teachers, schools, or students.

And in primary care now, with these new rules about having to focus on these very specific measures of "quality," patients' actual needs often go unmet. When a doctor only has 15 or 20 minutes with a patient, s/he has his/her "list" to get through, but the patient has his/her OWN "list" to get through, and often there's no time to do so. I experience this as a patient - my doctor has like this checklist she's trying to get through each time, my weight, current medications, blood pressure, breast exam, a list of "do you have [insert symptom here]?" yes-or-no questions, and usually this checklist of hers isn't at all what *I* want to be focusing on...but there's just no time. Physicians are stuck between a rock and a hard place. My SO feels it all the time - she wants to spend as much time with her patients as they need, to listen to them and develop trusting relationships with them, and she usually does so, and is usually behind schedule during the day. Her patients tell her how grateful they are to have her as a doctor, and thank her for listening and taking the time, and they're really happy with the care they're receiving. So why can't SO come home happy and satisfied at the end of the day, knowing she's providing excellent care to her patients? Because the more time and attention you give to the patients and their actual needs, the less time and attention you're giving to the stupid rules and requirements of the system, the paperwork, the busywork; you get punished for valuing quality more than quantity. If you put the time and energy into giving your patients excellent care, you come home at night with 18 un-written notes, every night, and can never catch up while still having a life of your own. It seems to me (but maybe I'm wrong), that if a doctor provided patients with excellent care and spent lots of time with each of them and received wonderful feedback from patients, but didn't get his/her notes in on time, s/he would be penalized by administration quite seriously...but if a doctor always rushed through appointments and was rather rude and dismissive with patients, it's really not that big of a deal, so long as the doctor gets his/her notes in on time and follows all the stupid rules - because if patients complain about being their doctor's behavior, eh, they can just go talk with a Patients Relations Specialist. It's so BACKWARDS to me.

OMG I need to stop ranting. Especially because my ranting has gone way beyond the actual topic of this thread.

[Liisi]

And YES, I often feel like I'm too much of an idealistic dreamer to be able to survive in the real world. It's been a life-long problem of mine.