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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.... there?

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.

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Comment Preferences

  •  I've run into this. (10+ / 0-)

    I have arthritis and fibromyalgia. For this, I take a mild opiate. (Sometimes, for flares and for my period at its worst, I take two.)

    I have severe ADHD. For this, I have in the past taken Adderall. I liked it. Not too expensive, morning dose wears off by the time I need to start winding down towards bed, no problem, gave me my brain back without twitchiness.

    I have occasional anxiety issues and vestibular system issues. Usually I can breathe through my anxiety, but it's nice to know that I've got ten or so lorazepam in the cabinet to stop it before it EATS MY HEAD ALL NIGHT LONG, just in case.

    I did evil things to my foot to get that arthritis. Sometimes I have muscle spasms in that calf and thigh due to that. Usually I can keep it at bay with stretching. Not always. In those instances, it's nice to have four or five Skelaxin handy to MAKE it relax. (And a half of one shuts down the feeling that my uterus is trying to invert itself completely, which is also helpful some days.)

    I am not going to be in for little stuff, I'm highly motivated to handle things on my own as far as I can, so all I need....

    is just prescriptions for an opiate, an amphetamine, a benzodiazapine, and a muscle relaxant.

    Yeah, I know what that looks like.  And I also know I haven't had all my drugs in a year, and have reacquainted myself with what it feels like to have vertigo so bad you can't get into bed. And how it feels when your uterus is cramping so hard you vomit.  And the shame and fury of realizing you forgot to call someone on time and left the milk in the trunk on a hot day and can't find the paperwork you need to turn in to establish eligibility.

    But god forbid it look like they're enabling an addict.

    Help me get my utilities on! I can't eat this elephant by myself.

    by Alexandra Lynch on Thu Jun 12, 2014 at 08:14:38 PM PDT

  •  once upon a time back in 1989 I was working for (10+ / 0-)

    doctors of the clinic A type. All of a sudden we had an incredible influx of new patients from our state and the neighboring state. We took 'em all until we burst and said we just can't see anybody else!! That was when it became clear that all the surrounding offices in both states had decided to stop taking medicaid patients at the same time, and we not only missed the memo, we wouldn't have done that anyway and we didn't stop seeing everybody until it just about crashed. The area offices opened up to them again a few months later, but it was almost a calamity.

    We are all pupils in the eyes of God.

    by nuclear winter solstice on Thu Jun 12, 2014 at 08:15:28 PM PDT

  •  Another issue that may not be immediately (8+ / 0-)

    obvious is ethnicity.

    I read recently that patients give better ratings to white doctors.  Also, patients of various races prefer doctors of their own ethnicity.  In this article, one doctor of color recounted how he/she would be asked to do janitorial tasks, or asked when the "real doctor" would be there.  

    This whole ratings system is fraught.  Another article over a year ago covered how doctors can fire patients:

    If the chart audit system discovers that a physician, for whatever reason, is an “outlier”–that she’s either not following the guidelines exactly or not getting the results anticipated for her patient population—she’ll be financially penalized. A quick example of what might occur: if your LDL is 115, you may be on the receiving end of a statin sales pitch from your doctor, not because bringing it down to 99 will improve your longevity, but because your refusal to do so will impact her financial bottom line.


    One physician piped up, “It’s one thing to have a healthy population of patients that never complains, follows all the rules, takes their generic medications, and never questions anything. But what about the non-compliant patients who won’t take the meds, don’t eat well, don’t have mammograms, continue to smoke? And what about super-health-conscious patients who want their vitamin levels measured and want referrals to acupuncturists?”

    Another physician answered wearily for the medical director (who didn’t disagree): “You’ve got to fire patients like that. Get the non-compliant and the super-demanding out of your system. They’ll drag your numbers down. Hit your personal bottom line.”

    © cai Visit to join the fight against global warming.

    by cai on Thu Jun 12, 2014 at 08:50:19 PM PDT

  •  Thank you for this account. (5+ / 0-)

    I hope you send this, with the actual names of the clinics, to someone who can do something about it -- or should do something about it.  Or pare it down and send it as a letter to the editor or a guest editorial.

    © cai Visit to join the fight against global warming.

    by cai on Thu Jun 12, 2014 at 08:53:21 PM PDT

  •  Great diary thanx (2+ / 0-)
    Recommended by:
    cai, FloridaSNMOM

    Beer Drinkers & Hell Raisers

    by Patango on Thu Jun 12, 2014 at 11:04:51 PM PDT

  •  The ACA left insurance companies in charge (0+ / 0-)

    The ACA left insurance companies in charge of our access to healthcare and then some of the law's defenders pretend to be outraged when they pull crap like this. Of course they are going to do anything and everything to maximize profit because that's what they are about, not healthcare. One can't simultaneously defend the ACA and condemn what the for profit insurance companies are doing to get around it, Not with any kind of intellectual honesty anyway.

    "Given the choice between a Republican and someone who acts like a Republican, people will vote for a real Republican every time." Harry Truman

    by MargaretPOA on Fri Jun 13, 2014 at 03:26:35 AM PDT

  •  its not just clinics (1+ / 0-)
    Recommended by:
    wilderness voice

    "metrics" are used to justify cost to companies as well-especially for big jumps so the fat asses of executives might have to fit narrow chairs by healthcare dollars being mandated toward actual care.  Our company was presented with a 40% increase because BC/BS stated they had spent 40% more on its healthcare. the hr department reviewed found that there was no actual increase in claims but that healthcare costs had increased about the usual amount well under 15% so what was the other 25%? much was projected increases predicted by metrics- employees tend to age over the years, young employees tend to marry and produce dependents which one would think would be built into their business model. Luckily, we could shop the markey and change insurers.

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