Making the grade
By Clare Hawkins, M.D., M.Sc.
TAFP President, 2013-2014
As I reviewed my children’s report cards recently, I found myself proud of their achievements. I also began reflecting on whether these grades were an accurate reflection of their past performance or current abilities. I know they worked very hard and deserved credit, and that being graded was a great deal of stress for them. Ultimately I found myself being thankful that I was no longer in the educational system where I was frequently under pressure to perform and be graded by teachers and professors. Then I stopped myself and considered the last report I received from a health plan which outlined my performance as a doctor. Unfair! How do they know how good I am? They don’t really know how well I perform.
Increasingly we physicians find that health plans, governments, or employers are evaluating the care that we provide. Do we know what they are measuring? Will it affect my payments? Will it affect my employment?
Whether we believe in certain aspects of health care reform, physician profiling is here to stay. And as I mentioned in my TAFP installation address, change is inevitable. We can take charge of the changes imposed upon us.
I am struggling to embrace the ways I am being measured by distilling the performance measurements into self-directed questions, such as:
Am I really prescribing dangerous drugs?
What proportion of my patients take the drugs that I prescribe (medication regimen adherence)?
Is it my responsibility?
Can my patients get in to see me?
Do my patients have to go to the emergency department and risk an expensive admission?
What are primary-care sensitive admissions?
Patient satisfaction metrics
Do my patients like me?
Do my patients feel healthier than they did the year before?
Have I kept them out of the hospital?
Many of the tools used to measure physician performance come from health care research, and have an evidence basis. Take, for example, the care of geriatric patients. It has been well established that multiple medications in the elderly interact with each other, and I should prescribe the least amount necessary. I should avoid prescribing more than six if possible. I should avoid anything that could sedate them or make them a fall-risk. However, many of my elderly patients have multiple diseases; many ask for sedatives, muscle relaxants, allergy treatments, or pain medications.
All of these have risks to them, and now...to me! In my well intentioned effort to prescribe for them, I can be seen as a “bad” doctor because I’ve prescribed something that I have prescribed for many years. Not only are they at risk for falling, but I’m at risk of falling out of a health plan. In this case, there is perhaps a good reason. Research has shown that by trying to help them, I am increasing their risk of falling and sustaining a femur fracture. In some cases, perhaps, the measurements can help me to practice better medicine.
If I continue to make medical decisions which place patients at risk, then I may not be able to see patients with that type of insurance. I may find that as health plans build limited networks, they may choose not to invite me into those networks, and my patients will be compelled to see different in-network physicians. Emerging accountable care groups are able to be selective about which doctors they include because they want to provide quality and efficient care. They may even cull their ranks when physicians fall out for either quality or efficiency.
But they don’t understand, “I’m actually a good doctor!” I am gentle, caring, and I carefully evaluate the individual patient in front of me. As I balance risks and benefits I may choose to take a prescribing “risk.” Now I must consider that the risk is not only to the patient but to me and my profile! What is a doctor to do?
I have several choices. I could choose to fight this assault on my autonomy, or I could engage my professional association to contest a specific measurement tool. I could also review the information behind the measurements and re-evaluate my current practice and make changes.
Whenever we participate in quality improvement activities, it has been shown that our real performance is often substantially less than we think it to be. Measurement is necessary to achieve better performance. Perhaps it would be better to measure my performance on certain criteria before I am measured by a health plan or by the government. Perhaps I can achieve higher numbers of eligible patients getting preventive tests such as colon cancer or breast cancer screening by measuring on an ongoing basis? Perhaps I can implement reminders, or authorize my staff to manage disease prevention activities. In a true medical home, more than just the physician is required to accomplish all of this care, but the physician should be the leader of the medical home team. Better that I should be in control of this process rather than having others force me to do it.
Being a doctor is more than just checking a box. We are experts at applying clinical guidelines to doctor-patient encounters. We can explain, negotiate, motivate, and find legitimate exceptions for the patient in front of us. Checking a box, however, can help our patients when it serves as a reminder to care for more than the just the presenting problem, but rather the whole patient.
When our new TAFP board met this December, we formed a subcommittee to review these issues and create programming for county academies, our regular CME sessions, and our publications to assist our members in coming to terms with the inevitability of a report card.
Will you be a “straight A” student?