The HIT Realist - What Paying Doctors for "Quality, Not Quantity" Really Means

It appears that many members of Congress have bought in to several unrealistic healthcare reform ideas, one of which is to change the way we pay doctors to a system based on “quality” rather than on “quantity” measurements, such as the number of office visits or procedures performed. They hope to get the same amount of work for a more significant cost savings. The way to implement this is to increase the bureaucratic oversight of physician performance, all the while making doctors pay for the cost of this increased burden. Over the years, several pay-for-performance trials have been run in which physicians, after a lot of reporting and data gathering, generally ended up being paid poorly, if at all, for their efforts. None of these trials have demonstrated a significant improvement in morbidity or overall survival. In some cases, the use of a “certified” EHR (c-EHR) actually was associated with worse outcomes and placed patients’ lives in danger.

What exactly is this “quality” mantra currently being touted by politicians, including our President? Already, the US has one of the best healthcare systems in the world, albeit the costliest. Life expectancy for US females has risen from 48 years in 1900 to 80 years in 2006; for males it’s risen from 46 years to 75 years. Our survival rates for cancer are better than those in Europe and Canada, where waiting lines for crucial imaging tests can take months, time for cancer patients that can mean the difference between living and dying. “Quality” is now defined as the achievement of the best outcomes for the least amount of money. Sometimes, the best outcomes, if too costly, will not fall into this new definition of “quality.” Americans are beginning to realize this, which is partly why more than 53% are against comprehensive healthcare reform.

On February 12, 2009, President Obama signed the HITECH Act, which put into law a poorly funded, poorly thought-out mandate that forces physicians to not only buy a c-EHR, but to also “meaningfully use” it. In return, US taxpayers will reimburse complying physicians up to $44,000 over five years. No further payments are scheduled to be offered after 2015; in fact, penalties of up to 5% of a physician’s Medicare income will become reality starting in 2016. I calculated in my March 2009 column that the process would cost each physician a minimum of about $60,000 per year to see Medicare patients based on a typical medical practice like mine; this cost is due not only to the up-front purchase of the c-EHR, but to ongoing monthly maintenance costs, costs related to the need for increased staff, costs related to the increased time it takes to see a patient in a “meaningful” way, and loss of time and income related to the cumbersome and slow electronic prescription mandate. If you multiply this cost by the number of physicians in private practice (~800,000), the yearly cost of “meaningfully” seeing Medicare patients would come out to $48 billion per year.

The federal government wants physicians to pay for all of this, which partially explains why the CDC published its biannual report on the state of EHR use in the US showing that only 6.3% of physicians are in a position to qualify for the HITECH reimbursement. Throughout the past 10 years, physician fees under Medicare have virtually been frozen, losing out to inflation to the point that it’s becoming harder for patients to find doctors who are willing to take on new Medicare patients. Asking physicians to perform costly “quality” pay-for-performance measures in this environment of decreasing reimbursement will doom the participation of physicians with Medicare.

Congress needs to repeal the HITECH Act, as well as any other similar costly bureaucratic mandates. Congress needs to offer physicians a free, open-source EHR, such as the VA Medical Center’s VistA EHR. Whatever EHR is offered, its interface must be easy to use and actually helpful with patient care to the point that it will entice doctors into “significant use” without any costly mandates, penalties, or other forms of punishment. This free EHR would be easy to interconnect with health information exchanges because of the same underlying structure and standards.

Politicians need to realize and understand that the new, unproven concept of “quality” will be disastrous to our healthcare system and will be a massive burden on our economy if fully implemented.