MCMS Physician Summer 2017 - 4

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Chairman's Remarks

Is Health Care
Right?
Value,A
Metrics
and Trust
Chairman's Remarks

MarkLopatin,
Lopatin,MD
MD
Mark
Chairman,MCMS
MCMSBoard
BoardofofDirectors
Directors
Chairman,

In this country, we are said

to haveour
inalienable rights to
Do
life, liberty and the pursuit of
patients
know?
happiness. Currently, there is a
sentiment out there that health
You have heard a lot in
care iscolumns
a right. and
Should
it be?
these
elsewhere

about
thedepends
problems
face
A lot
onwe
how
onein
medicine,
i.e.
how
policy
affects
defines what a right is. Basically
the
careisthat
we provide to
to a
a right
an entitlement
our
patients
and
threatens
the
particular service or concept.
patient-physician
relationship.
Some rights are independent
By the way, I call it the patientof an individual's actions,
physician relationship rather than the physician-patient
but many rights exist only in the company of associated
relationship because I think it is important to put the patient
responsibilities.
first.
Our current system does not do that. So what do we do
about
We complain
to the
each
other,tobut
watercooler
Forit?example,
we have
"right"
drive,
but this ispolitics
not
does
not
accomplish
much.
Many
of
us
are
not
even
aware
absolute. We must accomplish certain tasks, i.e. we
must
passof
the
changes
in
store.
If
physicians
are
not,
certainly
our
patients
a driver's test, purchase insurance, follow the rules of the road,
are
not.
and obtain and maintain a vehicle legally in order to be allowed
I wrote in a previous column that Value = Quality/Cost.
to drive. I think we would all agree, that someone who does not
This is now a standard equation in medicine. The problem is
have a license and who drives drunk, would not be able to use
that cost is easily measurable, but quality is not. Nonetheless,
"I have
right toofdrive"
as a valid defense.
with
thea repeal
the Sustainable
Growth Rate (SGR) and

the institution
of MACRA
(Medicare
and CHIP
When we talk
about rights,
there areAccess
two kinds:
things we
Reauthorization
Act)
and
MIPS
(Merit-Based
Incentive
already have, that no one is allowed to take away from us, and
Payment
that
is exactly
what the government will be
things thatSystem),
we do not
have
that someone
doing,
grading
and
rewarding
physicians
else must provide for us. Keep in mind thatbased on the quality of
care
whenprovided.
we talk about rights, we are talking
It would seem that on paper, paying physicians for
about our relationship with our government,
"value" would be a good thing, i.e. rewarding
not with each other.
physicians for "quality care" rather than for how
much or how little care they give.

So Let's Take a Closer Look

subjective and not prone to quantitative metrics. For example,
We have
the right
life.toBut
this iseverything
not absolute.
The death
some
patients
wanttome
explain
in detail.
Others
penalty
does
apply
and
can
be
used
in
the
right
circumstances.
just want my recommendation without explanation. So which
Likewise
we constitutes
have the right
to liberty,
but who
if we gets
commit
a crime,Who
of these
quality
care and
to decide?
thenwill
webe
candesigning
be imprisoned.
So
really,
rights
to
life
and
liberty
metrics and what will they be based on?areHow
relative
rights,
which
means
that aplay
government
can legally
takeand
will these metrics come into
in day-to-day
practice
those
rights
away
if
it
sees
fit.
Once
again,
our
behavior
dictates
what are the unforeseen ramifications?
whetherSuppose
we maintain
these rights.
as a rheumatologist,
one of the metrics for which
IWe
willhave
be graded
ontowill
whether
or not I get
DEXA
scans
the right
thebe
pursuit
of happiness.
Note
that we
for my
patients
65 and older.
If pursuit.
so, that But
should
be ano
do not
havefemale
the right
to happiness,
only its
again,
thing. After
all, recognizing
the possibility
onegood
is supposed
to be able
to take this away
from us. of and treating
osteoporosis is good medical care, isn't it?
All of these are things that we inherently have. What about
But, suppose I have a patient with active rheumatoid
things we do not inherently have, that must be provided by
arthritis (RA) that is difficult to control. If my focus is on
someone else? These may include things that we need to survive
making sure she gets a bone density scan, should I also address
such as food, shelter, and let's include health care. Are these
her RA at a given visit? If I address both at a visit, that means
rights?
that I am spending twice as long which means that I must
We do not
a right
to food.
havethat
a right
tomy
access
schedule
onehave
fewer
patient
or it We
means
all of
patients
to food,
justextra
like we
a right
the If
pursuit
of her
happiness.
wait an
15 have
minutes
thattoday.
I bring
back for a
Food
just does
notjust
exist.
It needs
be obtained,that
processed,
separate
visit
to focus
on to
osteoporosis,
means two
manufactured,
and stored by others who make it available to us
copays for her.
for a price.
We cannot
just walk
a grocery
store used
and take
If patient
satisfaction
is into
one of
the metrics
in
what
we want, quality,
with thewill
ideaI that
we havefor
a right
to food.
Having
measuring
get dinged
keeping
my other
saidpatients
that, as waiting?
a society we
try to provide
for those
fortunate,
Fordo
making
this patient
comeless
back
twice and
withpay
food
food
stamps,
twobanks,
copays?
What
if I etc.
order a DEXA, but the patient does
not comply? Should Likewise
I get dinged
that,there
too? are programs
withfor
shelter,
to try to provide shelter, but there are still
Third Party
Payers
Directing
Care
plenty
of homeless
people Medical
on the street.
They
do
not
have
a
right
to
walk
into
any
hotel
and
Good patient care does not exist in a vacuum and precommandeer
a
room
because
"I
have
a
right
determined metrics do not define it. Instead, good
to shelter."
medical
care is defined on a case-by-case basis. That

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

MCMS PHYSICIAN 4 SUMMER

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
2017
documenting what he or she has done rather than
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