Musings on Health Care Reform and…Things that Keep Me Up at Night

April 20, 2016 · Margaret E. O'Kane

I recently spoke about health care reform to a group of doctors at the 2016 Health Care Institute and Medical/Legal Summit and, to be frank, I was startled by their level of distress. They are truly troubled by a number of things.

• Pay for performance. Some doctors ask, if they try to do the right thing, is it fair to hold them accountable for the outcome of every patient, in every case? What about outlier patients with mental illness or a major life challenge? In some cases, doctors say, there’s little hope of getting patients’ health under control. Should doctors be penalized?
• Drug pricing. Doctors complain that drug prices are going through the roof. There are biologicals for which companies can name their price, or hedge-fund fanatics like Martin Shkreli; even drugs that were affordable a few years ago are pricey now, and nobody seems to be trying to stop it. Doctors worry they will be held accountable when their patients can’t afford to take their medications.
• High deductibles. Here, too, doctors ask an important question, “How can I take care of a patient who can’t afford to see me?”
• MACRA. Even doctors really don’t understand MACRA. They haven’t bought into alternative payment models, and nobody knows what that means yet.

As I step back from all of this, I wonder where the answers lie.

Who, or what, is the accountable entity?

Individual doctors, medical practices with team-based care? I think this is a real issue. Maybe doctors shouldn’t be responsible for patients who simply “won’t” get well.

If a primary care doctor practices in a system where patients are shared by a care team, is it fair or logical to call out that doctor’s individual performance?

Places that are excelling on quality measures tend to be highly integrated. They have good data systems and team-based care—doctors don’t need to focus on whether patients have had a scheduled mammogram or are up to date on their flu shot. Doctors know the system is taking care of these details, leaving them free to focus on the whole person and their more challenging patients.

We are schizophrenic about what we want.

We’re moving out of the era of the individual doctor as the accountable entity, but only with great difficulty. Most people still want “Marcus Welby, MD,” the kindly and knowledgeable doc, dispensing homespun wisdom, spending hours with patients—and making house calls! And many doctors want that, too; it’s why they went into medicine. The journey to a new way of delivering care has resulted in great frustration for both patients and physicians.

That said, the future of medicine is here, and it will be driven by knowledge derived from data. We’ll see treatment shifting to analytically driven guidelines, personalized to the patient.

We’re on a journey.  Leading organizations are still experimenting with how teams function and how to take advantage of systems without depersonalizing the care.

Change (management) is gonna come.

CMS can’t do it alone—but whose job is it? It’s everyone’s job. Leaders of practices and care organizations can grapple with the transformation because they understand the need. But the lives of individual doctors are changing profoundly in ways that they don’t appreciate and right now it doesn’t feel good to them.

So we have clashing policy initiatives: passing more financial risk to patients with high deductibles clashes with the idea that the system should ensure that patients are managed for optimal health.

Yes, a lot is happening, and it’s not feeling holistic – at least, not yet. And I lie awake at night, wondering how to get us there. So I ask myself and you to reflect on where NCQA may be a part of these problems and how can we be more a part of the solution.  As always, I welcome your thoughts and ideas!