Gaming the System

As physicians ready themselves for the future of medicine under onerous MACRA regulations, it seems appropriate to glance into the future and visualize the medical utopia anticipated by so many.  Value-based care, determined by statistical analysis, is going to replace fee for service.   

Six months ago, I received my first set of statistics from a state Medicaid plan and was told my ER utilization numbers were on the higher end compared to most practices in the region.  This was perplexing as my patients tend to avoid ER visits at all costs and can be found milling about in my parking lot at 7am on Mondays with their sick children waiting for my office to open. 

I requested more detailed reports on ER utilization and was given a 20 page list with codes that needed to be hand matched to patient names.  Being a committed and diligent physician, I spent a random Saturday evening matching up 420 names to individual 15-digit codes after putting my children to bed.  Of my top 20 utilizers, only 8 were actually patients.  The remaining 12 had been “on my panel list” during the reporting period but had never set foot in my office.  Of the top 100 utilizers, only 42 were patients.  In the interest of accuracy, I requested they re-run the numbers using my patients only.  Mr. IT informed me the inaccurate panel would make no difference.  He might have failed statistics in college but who is keeping track. 

I have spent 6 months on what I call obsessive-compulsive panel management (OCPM.)  My Medicaid panel has been closed for the last 9 months in anticipation of opting out by 2019.  OCPM meant 150 non-patients on my panel needed to be reassigned to primary care physicians who had space to accept them. Apparently, no physicians have requested this before, the insurance administrators were stumped as was the state department of health.  After more than 200 hours spent on this process (instead of seeing patients), I have whittled down the list to a comfortable 316 as of January 1st 2017. 

Last week, I received the second round of numbers, covering the period ending in the previous year.  Panel management was going on during this period but was by no means complete, so it is still not an entirely accurate reflection of my “quality”.  Mr. IT could not believe the difference in just one reporting period!  I would argue the accuracy of the panel had an impact on those statistics, but what do I know about such things?

He was excited that we have not admitted a single asthmatic patient in the entire reporting period, which is obscenely lower than the nearest practice in the region and the lowest in the state.  I almost told him we have not admitted an asthmatic patient in more than 15 years but thought he might have a heart attack.

Asthma admits will be metric #1 to demonstrate my high quality.  My ER utilization numbers are below the local region and on par with state numbers. I suspect accuracy is still not quite where it needs to be but have no interest in spending a free Saturday night matching up names and numbers manually to figure this out.  At least we are trending in the right direction.  There is metric #2. 

The search began for metric #3.  My frequency of ordering imaging studies (excluding X-rays) was above average.  Interesting, since I ordered only one test on a child with kidney stones last year.  After inquiring if the data reflected all scans done on patients from my panel or the just studies ordered by me personally, Mr. IT did not know.  He is working on it and will get back to me in a month or so, when he figures out how to do that sort of thing.  He could tell me there was a disproportionate number of echocardiograms ordered. 

Armed with that information, I could hazard a guess where my ‘quality problem’ lies; I have a large  population of children with cyanotic congenital heart disease, referred to me by a certain pediatric cardiac surgeon who thinks I provide quality primary care.  Many of these children get echocardiograms before and after cardiac surgery, other procedures, or whenever deemed clinically necessary by the specialist. 

Why do we have to employ an IT guy to give me information I already know?  Why is the government paying him to do something I can do in my head?  Why am I being penalized for a specialist ordering necessary imaging studies on pediatric heart patients?  How does this demonstrate quality again? 

The search for Metric #3 continued. I have many families who are vaccine hesitant or non vaccinating and do not have the heart to turn their children away.  Vaccination refusal is properly documented in the chart but the world of statistics does not account for these subtle nuances. There are companies emerging who can look at coding and catch specific words or phrases which help show quality.

While I have poorer numbers on percentage of immunized children, it turns out I had a perfect score on my mammogram recommendations. What mammogram recommendations?  Last year, I evaluated a parent having an asthma exacerbation and while I wrote her prescriptions, we discussed her family history of breast cancer and the need to schedule a mammogram.  My rate is at 100% because she is the only patient last year I evaluated who falls into this category and I happened to document the preventive recommendation purely by coincidence.  Bring on Metric #3.

MACRA lets physicians pick and choose which metrics are evaluated for “quality.”  This pediatrician is wholly committed to tracking mammogram recommendations at all applicable patient encounters in the future to demonstrate the highest quality patient care I am capable of providing.  I read a recent blog post from a cardiologist who might track how often he orders imaging for back pain, since he had a 100% score in that particular category. 

Imagine what quality metrics the pediatric cardiac surgeon is going to track.  He would do well to collect statistics on how often he images patients for appendicitis because it is likely a rare occurrence.  Things are really looking up for the use of data and technology in healthcare. Costs are likely to keep rising with everyone scoring in the 99th% percentile once they figure out how to game the system.  But we certainly cannot stand in the way of science or progress now can we?     

Niran al-Agba is a pediatrician based in Washington state. 

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  1. I think the Medicaid system (at least) could be greatly improved with a free market approach like the Healthy Indiana Plan 2.0. Beneficiaries get a $2,500 POWER (monetary) account that encourages them to look for their own value in physicians. Then they also get a High Deductible Health Plan to pay for health expenses if their monetary account runs out. It may not be perfect, but it sure beats the current system and gives even poor people choices. Hopefully this is less of a “top-down” approach.

  2. Brilliant. Data managers cannot handle the data they have with any responsibility…but they need more. If this is the kind of robo-management HHS thinks will salvage it…best of luck to them. Prepare for your great great grandchildren that have not been born yet funding our healthcare. Unfortunately, it will not even go towards care. It will go towards one ridiculous management fad after another. If HHS/CMS had any idea, they would be using existing claims data to see who is providing good care to begin with and then, heaven forbid, reward them. “Gaming” is being kind. This is “clowning”. And it isn’t the physicians who are producing it. We should not donate any more patient data to groups like HHS/CMS who have been so irresponsible with it. They have absolutely nothing to show for it. And the fact that some PCP has to go around correcting it in their spare time is a testament to how pathetic their efforts are.

    • Using existing claims data is the only solution that makes sense. But they will keep clowning for another few years I suspect. Thanks for reading!

  3. The only means for a solution is to identify every claim as to whether is was the result of a specific involvement by a Primary Physician (PCP). As long as Medicare continues to ignore a definable and verified Primary Physician for each Medicare-eligible citizen, there is no means for a solution. As a result, NONE of the metrics that currently apply to the performance of a PCP will be either accurate or meaningful. I seem to recall that Medicare’s claims evaluation process for identifying a person’s PCP is only @70% accurate.
    AND, where is our national professional organizations in the midst of this national fiasco? The acquiescence involved by a large centralized national institution, Medicare, that it wouldn’t be able to reliably keep track of a PCP is an unacceptable view of reality. I am reminded that 9 of the 90 Medical schools that have existed for more that 50 years, do not sponsor a Family Medicine residency. C. Wright Mills wrote a book published in 1956: “the POWER ELITE.” Its hard to ignore the institutional co-dependency between the payers and the Complex Healthcare providers as a basis for how our nation funds the health care for Basic Healthcare Needs. A Community by Community perspective for each person’s health care is ignored, and our nation’s maternal mortality ratio continues to worsen by a lot.

    • Right. 30% of the time HHS/CMS has no idea who the PCP or the actual driver of costs is. They could pull that from claims, but are too inept to do so. Why are we submitting more data to these people?

      • Exactly gentleman. Claims data is ready, available, cheap and efficient for a variety of reasons. Why do they need to reinvent the whole thing?

    • Yep. This is a lot of the reason we are fed up. Can you imagine having to spend time fixing the skewed data for accuracy instead of patient care. Makes you wonder why we went to medical school in the first place.

  4. Good post and example of how Q&P assessment can go wrong. My suggestion for you, Niran, and other front line docs who wants to weigh in: write Price and Seema Verma with concrete suggestions on how to make things better. The letter should start with assumption that MACRA is not going away, because that is the reality. It should also acknowledge that government (federal and state) has the right to hold docs accountable given that government pays almost half the nation’s health care tab. It will be critical for you and your colleagues to let the new folks know how how the system is working or not for you…now and as especially MACRA gets implemented. You and several other docs who write regularly for THCB are very articulate on the subject.

    • Thank you Steven. Seema is an innovative individual so I am encouraged by her taking over for that other guy. You are right MACRA is likely not to go away, but the docs will. Opting -out solves our dilemma, but the poor suffer. In anticipation of dropping Medicaid due to regulations, 20% of my practice is Medicaid down from 40% a year ago and 50% 2 years ago. What a shame.

      • I’ve read that a lot of primary care in rural areas is provided by NP’s and PA’s as compared to the more urban and suburban areas. Is that future for rural patients, especially those on Medicaid, as doctors leave, retire or at least stop seeing Medicaid patients?

        • Yes. We are headed to a two-tier system. The care will never be of the same quality delivered by NPs only, but the government is more interested in low cost than quality. It will become more obvious in life expectancy numbers over time. The good news is once we opt-out, patients can pay cash for visits when they really need them. Many already do once I dropped two contracts. This is the future.

          • I suspect that politicians would probably agree that they are more concerned about cost than quality in healthcare because they would say resources are finite and there is a limit to how much they can force their constituents to pay in taxes and still get re-elected. If they can satisfy themselves that care available to the poor is “good enough,” then they will claim they discharged their moral obligation to help the poor. Since most people who have a choice would choose more comprehensive insurance that pays doctors and other providers more than Medicaid does and is also comprehensive, we will indeed wind up with a two tier system — one for the poor and one for everyone else.

          • You are right that we are well on our way to a system for the poor and a system for everyone else. My frustration is it feels wrong. I went into medicine to help people from all walks of life with all sorts of medical problems. Who knew less than 20 years later the government and insurance industry would be working in direct opposition to me performing that job?

          • If you want to develop a system where patients are simply triaged to the appropriate specialist, we are headed in the right direction.

      • “You are right MACRA is likely not to go away, but the docs will. Opting -out solves our dilemma, but the poor suffer.”

        That is what is happening whether the physician leaves physically or intellectually, but some can’t seem to get the point. They have telescopic vision. I believe NP’s will replace physicians in many instances (they are already doing that today). Will that improve care? No. Those making policy on the one hand say physicians, despite their rigourous training, make too many mistakes and on the other hand say we need less trained NP’s to replace physicians.

        • Sorry to disappoint you, but NPs are pretty smart and can actually jump ship to a specialty, unlike most PCPs. Not seeing the replacement happening. But thanks for your effort to undermine wages for the same work. It is remarkable how the primary care shortage persists with such a successful effort.

          • Leo, not quite sure what you are trying to say. You say “but NPs are pretty smart” and no one disagreed with that, but do you believe that NP’s with less training are better prepared than M.D.’s with more training? I wasn’t discussing ‘smartness’ or the ability to move from one field to the other. I was discussing the amount of training for each individual and since many comment that physicians make too many mistakes do you believe that the mistakes will be reduced with less training?

            Who was undermining one’s wages? I don’t understand your comment. Maybe you are saying the physician should be paid less? Should a hospital LPN be paid the same as a nurse because both sometimes do the same things?

            I really don’t understand the direction of your comment.

      • Agree. A shame. Medicaid repair and shoring up should be part of what happens now…but alas it could go in the other direction. Medicaid reimbursement is a very tough problem that has been with us since the beginning.

        • The ACA dumped millions into the Medicaid program, but no one on the left seemed to care as long as they could say more people were being insured. They didn’t dump a lot of money in so competition for the dollars became even more keen and disadvantaged the poorest and least educated of the Medicaid patients. That is an example how socialism and the socialist mind works.

  5. Wonderful post. We need these types of experiences told over and over from front line MDs. I can tell you after years of PQRS reporting, value/quality is based SOLELY on ability to report not in ANY WAY indicative of outcome, quality, cost, value, etc. MACRA is more of the same. I do have a small amount of hope for the new admin, new HHS admin, etc.
    But the past 8 years, we suffered through MASSIVE explosion of complicated “Value” reporting mechanisms, that cost billions, devastated the practice of medicine with high quality MDs quitting, killing themselves, or turning to other professions and did NOTHING to improve care. The past 8 years obviously felt that Washington DC knows better than anyone, more regulations the better, more penalizing the better, more complicated the better.They could not understand that making yearly 2700 page policy changes didn’t help things.They really needed to go. They set up policy markets with Cert EHR, drove extreme consolidation of independent practices , hospitals, insurers, etc. Has that helped anyone? NO way. The ones left like Mommy Doc are the fighters, the last stand. And we are going to fight. We are NOT going to accept this anymore. We have been abused by CMS ONC insurers MOC MACRA MU PQRS P4P etc etc. The blowback is happening.

    • Thanks meltoots. I still have a small amount of hope with the new administration but he is getting distracted. In the past eight years with the massive EXPLOSION of value reporting, we sure are much better off aren’t we? Think of all the pediatricians who will be recommending mammograms now? 🙂

  6. Mr. IT is paid to make you look bad.That is his job, blame you and all the other doctors for the problems created by the mismanagement of the program. What do you think would happen if he blamed his boss? When your numbers appeared better on their flow charts they might even have given him a raise.

    Sometimes, if alternative Medicaid physicians don’t exist, they have no choice but to provide you with more favorable terms. I heard of one rural group that had committed fraud and abuse, but were the only one’s available for Medicaid patients in that large area. Instead of being thrown out of the program they were given favorable treatment because the program needed someone to provide Medicaid in that area and had no alternatives. I don’t know about this first hand so take it with a grain of salt, but I have seen how a lot of organizations work.

    We have a lot of similarities. You treat patients in their first childhood and I treated them in their second. We start with diapers and end the same. 🙂

    • Mr. IT is actually not a bad guy. He just doesn’t really know anything about medicine, which is my larger point. His boss is not much more knowledgeable either, which is the shame in all of this. Its kind of a garbage in-garbage out system.

      Your point is a good one. I am kind of like the rural group you mention, minus the fraud and abuse part. This week, I was informed yet another pediatrician is leaving town. A group that had 9 pediatricians when I set up shop is down to 3. Soon there will be NO alternatives… but maybe the tables will turn and physicians will have a voice… have you checked out Practicing Physicians of America? You might want to google it!

      • Can I assume that http://www.practicingphysician.org/our-mission.html is what you were talking about? I’m retired, retiring a couple of decades before I had intended only because of the hassel factor and the meanesss existing in government that carried through to the insurers that were trying to live up to dumb rules and regulations.

        If physicians believe in big government they will eventually subjugate themselves to the status of a widget and become another instrument that treats code numbers rather than patients. If they are willing to maintain their independence they will carry a greater risk, but I believe it is only then that they can hold their heads high as physicians.

  7. How do the IT geniuses determine which patients are on your panel and how to they account for care delivered to patients who don’t have a primary care doctor? Can’t doctors easily provide a list of people on their patient panel? If so, why can’t the IT folks use that?

    • Ah Barry, I have started looking forward to your thoughts on my posts. I really think you need to consider getting involved in this process and helping us change it for the better.

      Panels are about “what insurance companies decide you have” not about “what the physician thinks they have.” Those are direct quotes from a “value-based care” seminar I attended recently. The speaker said “insurance is king.” Ridiculous notion.

      I really want to see my patients, by the way. This is why I became a doctor.

      So Medicaid assigns physicians random patients who move into the area and we have no control unless we close our panels entirely. My concern has always been that these patients assigned to me but who are not seeing me (because I am full) are not receiving the opportunity to have a PCP. This argument continually falls on deaf ears. Medicaid doesn’t care about delivery of healthcare; they are interested in measurements of healthcare. That is the problem. Care is not found in calculations.

      For the past six months, I have requested a pilot project where I am given the “authority” to manage my own panel in the database. I have patients who live 2 hours away in other counties who drive to see me and keep getting switched to other PCP’s. I would like to manage my own list as I know who they are and have a relationship with them.

      Most of the list contains inconsistencies like “needs Well child exam” even though I just did a physical within the past few months. It is frustrating when I could just change that information or at least flag it for someone else to evaluate and correct. But so far, to no avail.

      • Thanks Niran. While I would love to see the healthcare system change for the better, I’m not a doctor and have never worked in the healthcare field in any capacity. My 40 year career was in the money management business and I’ve been retired for five years now.

        Therefore, I don’t think anyone in a policymaking capacity would assign much credibility to anything I might have to say. I enjoy commenting on these blogs though, have learned a lot about healthcare and continue to. Please keep the essays coming..

    • Barry, essentially the same nice IT geniuses have worked in different positions throughout the years doing the bidding of their employers. The job title changes slightly, but the answers provided don’t vary all that much. When HMO’s were growing and when they were at the pinnacle of success they too manipulated the data. I never contracted with any HMO’s, but the HMO’s needed doctors and specialists to fill up their lists. Thus my name was included by some of them even listing me under several specialty categories at the same time. Even registered letters didn’t get my name removed from the lists for their goal was to make their physician provider list look like it was full of the best doctors.

      I did accept some managed care and occasionally I received statistics just like Niran’s being told I was an outlier when it wasn’t true. Things haven’t changed that much.

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