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Quality-Based Reimbursement Unfair to Physicians


Noncompliant patients could hurt physician quality scores under MACRA and reduce their compensation. How will that affect the doctor-patient relationship?

The healthcare changes that are on the horizon for physicians in 2017 bring to mind the recent reforms in public education. The education reforms were designed with the best goals in mind - to improve the futures of American children by creating rigorous standards and holding educators accountable for meeting those standards. However, even good things can become complicated. In some states, test scores are used to demonstrate the effectiveness of the teachers and are factored into their compensation.

Reducing a child to a data score is overly simplistic. We know that children are all different, bringing to the classroom a variety of abilities, challenges, and backgrounds. Is it fair to make a teacher's salary dependent on how well the children assigned to her class perform?

Now, through the new MACRA regulations, a similar approach is being leveled at physicians. Starting next year, doctors will have to report on a number of data points and must demonstrate "quality" in order to receive a certain level of compensation. The scores will even be made public. But is this fair to doctors? And perhaps even worse, is it fair to patients?

In education, we can see how difficult it is when a teacher has a student who does not attend class regularly, is never prepared with homework, and is obviously not well rested. Even the very best teacher would struggle to help that child successfully meet the curriculum mandates. It's easy to imagine how frustrated the teacher would become, especially if her salary was dependent on that child's test scores. It's only logical that teachers would want only the "good" students in their class. What happens to the child with special education needs or the one who comes from a family that doesn't put value on schooling or education? This approach is unfair to the teacher, and the child who doesn't deserve to be marginalized.

It's the same with physicians. If a doctor has a patient who is diabetic, needs to take medication, and make lifestyle changes, but that patient won't comply with treatment recommendations, what can a doctor do? If the doctor orders a follow-up appointment, but the patient doesn't show up, how can the doctor help prevent problems downstream?

Doctors understand there is a lot of psychology at play when it comes to getting patients to actively manage their health. Many good people who truly want the best for themselves get scared by health warnings and move into denial mode. Problems can get worse. Physicians know how to treat these patients with compassion and patience, moving them along the path to better health the best they can. But if noncompliant patients will hurt physicians' overall quality score and reduce their compensation, what happens to the all-important doctor-patient relationship? Just like with the teacher-student relationship, trust is broken.

Public school teachers can't dismiss the students in their class to improve their scores. They work with the class they are given. But what about private doctors? What we would never want to see is physicians deselecting patients based on how they would impact their quality scores. Moving complicated patients toward better health is the ultimate goal of physicians, and they shouldn't have to be penalized for fulfilling their mission. Further, unlike a child's score on a state test, the physician's inputted data is subjective and open to interpretation. Can we trust that the data is accurate?

Educational reforms need to take into account the range of students a teacher receives and attempts to educate. Healthcare reforms need to consider the range of patients too. It's easy to demonstrate quality with well-heeled patients who make their health a priority. But low-compliance patients need to be nurtured, and doctors shouldn't be penalized for taking on the difficult cases.

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