MCMSPhysicianSpring2017 - 4

mon t m e d s o c .c om

Chairman's Remarks

Value, Metrics and Trust
Mark Lopatin, MD
Chairman, MCMS Board of Directors

Do our
patients know?
You have heard a lot in
these columns and elsewhere
about the problems we face in
medicine, i.e. how policy affects
the care that we provide to
our patients and threatens the
patient-physician relationship.
By the way, I call it the patientphysician relationship rather than the physician-patient
relationship because I think it is important to put the patient
first. Our current system does not do that. So what do we do
about it? We complain to each other, but watercooler politics
does not accomplish much. Many of us are not even aware of
the changes in store. If physicians are not, certainly our patients
are not.
I wrote in a previous column that Value = Quality/Cost.
This is now a standard equation in medicine. The problem is
that cost is easily measurable, but quality is not. Nonetheless,
with the repeal of the Sustainable Growth Rate (SGR) and
the institution of MACRA (Medicare Access and CHIP
Reauthorization Act) and MIPS (Merit-Based Incentive
Payment System), that is exactly what the government will be
doing, grading and rewarding physicians based on the quality of
care provided.
It would seem that on paper, paying physicians for
"value" would be a good thing, i.e. rewarding
physicians for "quality care" rather than for how
much or how little care they give.

A Major Problem: Defining Quality
Quality may mean different things to
different people. Furthermore, quality for a
population of patients is different than quality
for an individual patient. Quality is inherently

subjective and not prone to quantitative metrics. For example,
some patients want me to explain everything in detail. Others
just want my recommendation without explanation. So which
of these constitutes quality care and who gets to decide? Who
will be designing metrics and what will they be based on? How
will these metrics come into play in day-to-day practice and
what are the unforeseen ramifications?
Suppose as a rheumatologist, one of the metrics for which
I will be graded on will be whether or not I get DEXA scans
for my female patients 65 and older. If so, that should be a
good thing. After all, recognizing the possibility of and treating
osteoporosis is good medical care, isn't it?
But, suppose I have a patient with active rheumatoid
arthritis (RA) that is difficult to control. If my focus is on
making sure she gets a bone density scan, should I also address
her RA at a given visit? If I address both at a visit, that means
that I am spending twice as long which means that I must
schedule one fewer patient or it means that all of my patients
wait an extra 15 minutes that day. If I bring her back for a
separate visit just to focus on osteoporosis, that means two
copays for her.
If patient satisfaction is one of the metrics used in
measuring quality, will I get dinged for keeping my other
patients waiting? For making this patient come back twice and
pay two copays? What if I order a DEXA, but the patient does
not comply? Should I get dinged for that, too?

Third Party Payers Directing Medical Care
Good patient care does not exist in a vacuum and predetermined metrics do not define it. Instead, good
medical care is defined on a case-by-case basis. That
is the whole problem with MACRA and MIPS.
Qualitative attributes simply cannot be quantified.
Furthermore, the key to all of this is how
a physician documents what he or she has done.
We have become more invested in a physician
documenting what he or she has done rather than
what the physician has actually done. It is more


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