Remember HMOs? Remember capitation? Remember insurance plans that penalized doctors for the "crime" of having a "sick" patient---making it all but impossible for sick and disabled people to find a doctor and get the care they needed? There is a new variation on the old theme. It is called health "metrics". Insurers claim that they can tell how "good" a doctor is. You know, the way that HMO's used to tell how "good" a doctor was by how little money he spent.
No, really this is better. This is not about money. This is about quality. This is about how many things he does for his patients. The more things he does the better. It is about how well he screens them for disease. There is no way that a metric could be abused....
Imagine two clinics, Clinic A and Clinic B. They are located in the same city. They are part of the same charitable public clinic system. They serve the same low income, uninsured patients. And, they both have to "prove" that they are delivering quality patient care. How do you prove an intangible? Right now, it is all about "metrics." How many of your female patients over 40 have had their annual mammogram? How many patients over 50 have had a colonoscopy. Are people getting their flu vaccines? How many people who fill out surveys rate their doctor as "excellent"? How long do patients have to wait for an appointment? How many diabetics have had an eye exam? Have an a1c under 8?
These "metrics" are important numbers. They determine raises. Bonuses. Who gets promoted. Who gets to take control of large piles of public cash which go to fund health care for the indigent. With so much as stake, you can't blame a savvy clinic director or manager for trying to find shortcuts. It is hard to get a homeless patient who does not speak English to get a mammogram. It is easy to get a low income English speaking computer literate health conscience graduate student to get her health screens done. It is easy to control the diabetes in someone with mild diabetes. It is difficult to keep that A1c under 8---another metric---if the diabetic is blind, has no feet, has no money, and is on insulin he can not afford.
So, what do you do, if you are Clinic B and if you want to prove that you are the clinic that deserves the funding? Do you try harder? Can you really hope to get that blind, double amputee diabetic's a1c down below 8? No. No matter how hard you try, you know that you can't do it. So, you do something much easier. You send the blind, double amputee brittle diabetic to clinic A, your rival. You hold on to as many healthy, borderline poor, compliant, health conscious, normal weight, English speaking literate patients as you can attract, and you find some pretense to send the medically "complicated" patients away. They were "noncompliant." They missed too many appointments---it is sort of hard for a blind, double amputee to get to the clinic sometimes. You tell a patient "No, you can't have any valium for your nocturnal spasms for your multiple sclerosis but there is a doctor as clinic A who will write that prescription." You say "No, I can't prescribe pain pills for your mother's cancer, but the doctors at clinic A can." You schedule them with doctors at clinic A.
What do you do if you are clinic A and you happen to believe that your charitable clinic system is here to serve the poor and the disabled? Do you send back the sick, illiterate, noncompliant, pain wracked, mentally ill patients that clinic B keeps dumping on you? Or, do you gather them into the fold of your already bursting at the seams practice and try to give them the care they need, too, even though your facility's resources are already stretched to the maximum? Even if it means that your doctors are now seeing too many patients each day, and the patients are mad because they have to wait for appointments, so they write angry evaluations. It's ok. You can put up with the abuse. You have to. Someone has to do the right thing.
Say Clinic A "does the right thing" because Clinic B won't? What happens to Clinic A's "metrics"? That's right. They go into the toilet. What happens to Clinic B's metrics? That's right. They shine. And what happens the next time all the clinics in the system are evaluated? Clinic B is held up as a model of efficiency and quality care, while clinic A is warned sternly that it must try harder. Clinic B's director gets a promotion. Clinic B gets more money. Clinic A eventually gets shut down. Clinic A's physician gets fired. because he is such a crappy doctor. Only a crappy doctor would have such bad metrics. And now all those poor, mentally ill, pain wracked, "complicated" patients have no doctor---and it's their own fault. They should not have been so sick and poor. Public health is not here to serve the sick and poor. It is here to serve the careers of those who work for it.
There is no link. This is a 100% real story. I am the eyewitness. I won't tell you in what major metropolitan area it is happening. It is very likely happening in the city where you live. And in the VA where your dad goes. This is what happens when you use something as easily manipulated as a "metric" to determine quality of care.
And it gets worse. Lots of private insurers use metrics. They know that doctors who are attempting to improve their own "metrics" in order to improve their reimbursement and avoid being de-selected by insurance plans will quickly realize that the easiest way to do it is to dump all the sick and poor patients. What? You don't think that doctors in private practice would do something like that? You don't think they could live with themselves if they sent away the sick and the poor in order to increase their own profits? If those who are charged with taking care of the sick and the poor---employees of our public health clinics will resort to such tactics in order to increase their power within a public health system, then anyone will. And when health insurance companies talk about "quality" what they really mean is the quality of the money they make selling policies to people who never get sick, while driving sick people into the arms of their competitors.
Something to think about the next time you are guilty of going to see a doctor while being sick and poor.