This week I had a patient in my office to follow up on her diabetes and high cholesterol.
She had spent almost five years without insurance and in May finally qualified for Medicare. So we went to work catching her up on all of the care she had not been able to receive for so long. Colonoscopy, bloodwork, mammogram, PAP, etc.
In the process we diagnosed her with diabetes and high cholesterol and started her on medication for these issues. She has worked hard losing weight. Her blood sugars are running in the 90’s before breakfast.
“Doc, I know you want to do blood work but I just can’t afford it today. I am so sorry!” She looked near to tears.
What a lot of patients don’t know is that I am measured on their numbers. Blood pressure, cholesterol, A1C, BMI…
Her numbers were awful last time. Those bad numbers are registered on her record. They are probably good now, but the only way to get those recorded and for me to get credit for those improvements is to do blood work. I can’t simply say, “Not indicated,” and skip doing it. I can’t make up those numbers.
Medicare part B does not cover 100% of everything. Patients are generally responsible for 20% of outpatient charges. So a fair amount of the cost of these tests is transmitted to the patient. She is not able to afford a supplement to pick up the remaining 20%.
What complicates matters is that her mammogram caught a mass. Turns out it was breast cancer. Thankfully we caught it just in time and she should do fine. She has had surgery and will start radiation this next week.
So from a money standpoint, right now what is most important? Getting her breast cancer treated or making my/her numbers look good?
KateCrimmons (She is awesome, check out her blog!) made a comment on my last post that got me thinking about this.
Sure, I could pressure her out of my own self interest and get her better numbers registered. She would do it if I made an issue of it.
But is that right?
How well I do on numbers affects my ratings with insurance companies. I get rated on the quality of my care on their websites (high ratings mean my numbers are good). And my numbers are flowed by Medicare. They are also followed by my employer. In fact, 5% of my income is tied to how I do on these quality measures and 5% is tied to my patient satisfaction scores.
Emphasizing quality IS a good idea!
I think as a whole the medical profession is doing a better job at this than we have in the past. There is nothing more infuriating to me than to have a young, otherwise healthy people with diabetes come to me saying their last doctor told them that their A1C of 7.8 was good. It is NOT good!!! When my name gets sent out to all of the physicians in my group, I want to be at the top of the list with my numbers better than everyone else’s. That means I am a better doctor, right? (Suck it all you losers! I rock!!!) It motivates doctors to follow evidence based guidelines and get those A1C’s under 7.0 in appropriate patients and prevents diabetic complications.
But there is a dark side.
When physicians start feeling the pressure financially, I believe they are going to be more inclined to make decisions for patients that are not necessarily in their best interest:
Pressuring patients to get blood work or take certain meds that may not actually be best for them. Firing the noncompliant diabetic rather than helping them to get compliant. Firing or not accepting overweight patients.
In fact this is already happening among my peers. We talk about it. I have pondered it myself, I will admit.
How do we balance quality in a way that is in the best interest of our patients?!?! Do we incentivize or penalize? How far do we take it? Is it OK to fire a patient for not losing weight or controlling their blood pressure? If we force them to seek another physician are we helping them by forcing them to think about their “bad” behavior so they will maybe work harder next time or serving them by having them maybe find a physician that can eventually reach them and get them to change their ways?
Thoughts from you?