During this presidential election year, much of the debate on healthcare will remain focused on the Affordable Care Act, otherwise known as Obamacare. Yet it is impending changes from another recently passed legislation that could even more drastically transform the American healthcare system.
In 2015, the Medicare Access and CHIP Reauthorization Act authorized Medicare to establish new models of payment. One in particular, called the Merit-Based Incentive Payment System (MIPS), will consolidate the various existing quality-reporting programs. Starting in 2017, most doctors and hospitals will be required to participate, and will report to Medicare their performance on measures such as how frequently patients were screened for high blood pressure. The score they receive based on these measures will directly affect their Medicare payments.
Take for example the quality measure of whether doctors counseled their overweight patients about healthy diet or exercise. Such lifestyle counseling is a fundamental part of high quality preventive care, and, if done thoughtfully, can be a powerful motivator for healthier behavior. But counseling is not often recorded in the chart, and there is no consistent way to measure the quality of such discussions. For these reasons, the standard way to measure these kinds of quality metrics became adding new checkboxes into the electronic health records, which are counted and reported back to Medicare at the end of each year.
Checkboxes are great equalizers. One doctor may spend a few minutes to carefully review a patient’s diet, while another may offer a casual reminder to “eat healthy”—yet what is counted in the end is whether the box was checked. Equating quality to a check box, however, risks crowding out the innate, professional commitment to high quality, patient-centered care that many doctors take pride in.
At a recent health IT meeting I attended, the organizers recounted a story about a quality measure from the Meaningful Use Program that required clinics to demonstrate their patients sending electronic messages through the patient portal. One clinic therefore had the front desk log patients onto the portal as they arrived for appointments, to send a message, “Hello”, to the doctor who is about to see them. While this kind of practice is likely rare, the reality is that when checkbox quality measures are tied to significant financial incentives, healthcare organizations and doctors, as rational actors, are driven to behavior that promote box checking.
The proliferation of checkboxes, however well intended, can also cause harm beyond wasted time and resources. By increasing the complexity of documentation in the electronic health records, checkbox quality measures can further decrease the time doctors spend listening to and talking with patients. As a recently published study in the journal JAMA Internal Medicine suggests, the more that doctors focused on the electronic health records during clinic encounters, the less likely their patients were satisfied with the care provided. On the physician side, for the many primary care providers who already face increased time constraints and who often are responsible for reporting on many measures, the ever-increasing emphasis of being graded on checking boxes can further erode morale and increase burnout.
For the MIPS program to successfully reward high quality care, perhaps the solution is to focus on quality measure that of higher quality than checking a box. Some measures that are already reported, such as how well blood pressure and diabetes are controlled, are objective, easy to collect, and meaningfully describe the health of a population of patients; these should therefore be continued. Check box measures that created perverse incentives should be removed, or replaced with innovative approaches such as using clinical data to identify patients at risk who can be surveyed directly, to see if they received the appropriate preventive counseling. Finally, there should be ongoing assessment to ensure that quality measurement is not incompatible with clinical workflow and electronic health records capability, and that reporting leads to improved clinical outcomes, not unintended harm.
The Harvard health economist Rashi Fein once remarked that, “in healthcare, the invisible hand is all thumbs”. The endeavor to improve quality by paying for it attests to the need for careful guidance for the “invisible hand”. Yet aligning payment to quality in the US healthcare system is long overdue. For the Medicare Access and CHIP Reauthorization Act to succeed, and for the sake of patients and physicians alike, we must begin by ensuring that the measurement of quality should measure the right things, to focus on what is meaningful rather than what a checkbox can provide.
Ye is a general cardiologist at Columbia University Medical Center and a Public Voices OpEd fellow.