Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

MACRA makes it easy to game the system

Niran S. Al-Agba, MD
Physician
March 7, 2017
Share
Tweet
Share

As physicians ready themselves for the future of medicine under onerous MACRA regulations, it seems appropriate to glance into the future and visualize the medical utopia anticipated by so many.  Value-based care, determined by statistical analysis, is going to replace fee for service.

Six months ago, I received my first set of statistics from a state Medicaid plan and was told my ER utilization numbers were on the higher end compared to most practices in the region.  This was perplexing as my patients tend to avoid ER visits at all costs and can be found milling about in my parking lot at 7 a.m. on Mondays with their sick children waiting for my office to open.

I requested more detailed reports on ER utilization and was given a 20-page list with codes that needed to be hand matched to patient names.  Being a committed and diligent physician, I spent a random Saturday evening matching up 420 names to individual 15-digit codes after putting my children to bed.  Of my top 20 utilizers, only 8 were actually patients.  The remaining 12 had been “on my panel list” during the reporting period but had never set foot in my office.  Of the top 100 utilizers, only 42 were patients.  In the interest of accuracy, I requested they re-run the numbers using my patients only.  Mr. IT informed me the inaccurate panel would make no difference.  He might have failed statistics in college but who is keeping track.

I have spent six months on what I call obsessive-compulsive panel management (OCPM).  My Medicaid panel has been closed for the last nine months in anticipation of opting out by 2019.  OCPM meant 150 non-patients on my panel needed to be reassigned to primary care physicians who had space to accept them. Apparently, no physicians have requested this before; the insurance administrators were stumped as was the state department of health.  After more than 200 hours spent on this process (instead of seeing patients), I have whittled down the list to a comfortable 316 as of January 1st, 2017.

Last week, I received the second round of numbers, covering the period ending in the previous year.  Panel management was going on during this period but was by no means complete, so it is still not an entirely accurate reflection of my “quality.”  Mr. IT could not believe the difference in just one reporting period!  I would argue the accuracy of the panel had an impact on those statistics, but what do I know about such things?

He was excited that we have not admitted a single asthmatic patient in the entire reporting period, which is obscenely lower than the nearest practice in the region and the lowest in the state.  I almost told him we have not admitted an asthmatic patient in more than 15 years but thought he might have a heart attack.  Asthma admits will be metric #1 to demonstrate my high quality.  My ER utilization numbers are below the local region and on par with state numbers. I suspect accuracy is still not quite where it needs to be but have no interest in spending a free Saturday night matching up names and numbers manually to figure this out.  At least we are trending in the right direction.  There is metric #2.

The search began for metric #3.  My frequency of ordering imaging studies (excluding X-rays) was above average.  Interesting, since I ordered only one test on a child with kidney stones last year.  After inquiring if the data reflected all scans done on patients from my panel or the just studies ordered by me personally, Mr. IT did not know.  He is working on it and will get back to me in a month or so, when he figures out how to do that sort of thing.  He could tell me there was a disproportionate number of echocardiograms ordered.

Armed with that information, I could hazard a guess where my “quality problem” lies; I have a large population of children with cyanotic congenital heart disease, referred to me by a certain pediatric cardiac surgeon who thinks I provide quality primary care.  Many of these children get echocardiograms before, and after cardiac surgery, other procedures, or whenever deemed clinically necessary by the specialist.

Why do we have to employ an IT guy to give me information I already know?  Why is the government paying him to do something I can do in my head?  Why am I being penalized for a specialist ordering necessary imaging studies on pediatric heart patients?  How does this demonstrate quality again?

The search for metric #3 continued. I have many families who are vaccine hesitant or nonvaccinating and do not have the heart to turn their children away.  Vaccination refusal is properly documented in the chart, but the world of statistics does not account for these subtle nuances. There are companies emerging who can look at coding and catch specific words or phrases which help show quality.

While I have poorer numbers on the percentage of immunized children, it turns out I had a perfect score on my mammogram recommendations. What mammogram recommendations?  Last year, I evaluated a parent having an asthma exacerbation, and while I wrote her prescriptions, we discussed her family history of breast cancer and the need to schedule a mammogram.  My rate is at 100% because she is the only patient last year I evaluated who falls into this category and I happened to document the preventive recommendation purely by coincidence.  Bring on metric #3.

MACRA lets physicians pick and choose which metrics are evaluated for “quality.”  This pediatrician is wholly committed to tracking mammogram recommendations at all applicable patient encounters in the future to demonstrate the highest quality patient care I am capable of providing.  I read a recent blog post from a cardiologist who might track how often he orders imaging for back pain, since he had a 100 percent score in that particular category.

Imagine what quality metrics the pediatric cardiac surgeon is going to track.  He would do well to collect statistics on how often the images patients for appendicitis because it is likely a rare occurrence.  Things are really looking up for the use of data and technology in healthcare. Costs are likely to keep rising with everyone scoring in the 99th percentile once they figure out how to game the system.  But we certainly cannot stand in the way of science or progress now, can we?

ADVERTISEMENT

Niran S. Al-Agba is a pediatrician who blogs at MommyDoc.  

Image credit: Shutterstock.com

Prev

Here's how and why patients lose in our current system

March 7, 2017 Kevin 2
…
Next

Bereaved families need a compassionate presence

March 7, 2017 Kevin 0
…

Tagged as: Pediatrics

Post navigation

< Previous Post
Here's how and why patients lose in our current system
Next Post >
Bereaved families need a compassionate presence

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

More by Niran S. Al-Agba, MD

  • Is there hope for COVID with home visits?

    Niran S. Al-Agba, MD
  • A tale of two epidemics: COVID and obesity

    Niran S. Al-Agba, MD
  • Delivering health care at a retail clinic isn’t something to be proud of

    Niran S. Al-Agba, MD

Related Posts

  • Physicians who don’t play the social media game may be left behind

    Xrayvsn, MD
  • A physician’s addiction to social media

    Amanda Xi, MD
  • Physician Suicide Awareness Day: Where are the patients? 

    Jennifer M. Sweeney
  • A nurse’s reaction to MACRA haters

    Carrie J. Whitaker, RN
  • Telemedicine should be easy. Here’s why it’s not.

    Dennis Wichern
  • Physicians and patients are now pawns in a political game

    Nicole M. King, MD

More in Physician

  • Adriana Smith’s story: a medical tragedy under heartbeat laws

    Nicole M. King, MD
  • Why U.S. health care pricing is so confusing—and how to fix it

    Ashish Mandavia, MD
  • From survival to sovereignty: What 35 years in the ER taught me about identity, mortality, and redemption

    Kenneth Ro, MD
  • When doctors forget how to examine: the danger of lost clinical skills

    Mike Stillman, MD
  • When the white coats become gatekeepers: How a quiet cartel strangles America’s health

    Anonymous
  • The man in seat 11A survived, but why don’t our patients?

    Dr. Vivek Podder
  • Most Popular

  • Past Week

    • Why removing fluoride from water is a public health disaster

      Steven J. Katz, DDS | Conditions
    • When did we start treating our lives like trauma?

      Maureen Gibbons, MD | Physician
    • Why male fertility needs to be part of every health conversation

      Hoag Memorial Hospital Presbyterian | Conditions
    • How home-based AI can reduce health inequities in underserved communities [PODCAST]

      The Podcast by KevinMD | Podcast
    • Inside human trafficking: a guide to recognizing and preventing it [PODCAST]

      The Podcast by KevinMD | Podcast
    • Graduating from medical school without family: a story of strength and survival

      Anonymous | Education
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • The silent toll of ICE raids on U.S. patient care

      Carlin Lockwood | Policy
    • My journey from misdiagnosis to living fully with APBD

      Jeff Cooper | Conditions
    • Addressing the physician shortage: How AI can help, not replace

      Amelia Mercado | Tech
    • Why does rifaximin cost 95 percent more in the U.S. than in Asia?

      Jai Kumar, MD, Brian Nohomovich, DO, PhD and Leonid Shamban, DO | Meds
  • Recent Posts

    • How home-based AI can reduce health inequities in underserved communities [PODCAST]

      The Podcast by KevinMD | Podcast
    • Adriana Smith’s story: a medical tragedy under heartbeat laws

      Nicole M. King, MD | Physician
    • What if medicine had an exit interview?

      Lynn McComas, DNP, ANP-C | Conditions
    • Why U.S. health care pricing is so confusing—and how to fix it

      Ashish Mandavia, MD | Physician
    • From survival to sovereignty: What 35 years in the ER taught me about identity, mortality, and redemption

      Kenneth Ro, MD | Physician
    • When doctors forget how to examine: the danger of lost clinical skills

      Mike Stillman, MD | Physician

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 7 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

  • Most Popular

  • Past Week

    • Why removing fluoride from water is a public health disaster

      Steven J. Katz, DDS | Conditions
    • When did we start treating our lives like trauma?

      Maureen Gibbons, MD | Physician
    • Why male fertility needs to be part of every health conversation

      Hoag Memorial Hospital Presbyterian | Conditions
    • How home-based AI can reduce health inequities in underserved communities [PODCAST]

      The Podcast by KevinMD | Podcast
    • Inside human trafficking: a guide to recognizing and preventing it [PODCAST]

      The Podcast by KevinMD | Podcast
    • Graduating from medical school without family: a story of strength and survival

      Anonymous | Education
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • The silent toll of ICE raids on U.S. patient care

      Carlin Lockwood | Policy
    • My journey from misdiagnosis to living fully with APBD

      Jeff Cooper | Conditions
    • Addressing the physician shortage: How AI can help, not replace

      Amelia Mercado | Tech
    • Why does rifaximin cost 95 percent more in the U.S. than in Asia?

      Jai Kumar, MD, Brian Nohomovich, DO, PhD and Leonid Shamban, DO | Meds
  • Recent Posts

    • How home-based AI can reduce health inequities in underserved communities [PODCAST]

      The Podcast by KevinMD | Podcast
    • Adriana Smith’s story: a medical tragedy under heartbeat laws

      Nicole M. King, MD | Physician
    • What if medicine had an exit interview?

      Lynn McComas, DNP, ANP-C | Conditions
    • Why U.S. health care pricing is so confusing—and how to fix it

      Ashish Mandavia, MD | Physician
    • From survival to sovereignty: What 35 years in the ER taught me about identity, mortality, and redemption

      Kenneth Ro, MD | Physician
    • When doctors forget how to examine: the danger of lost clinical skills

      Mike Stillman, MD | Physician

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

MACRA makes it easy to game the system
7 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...