MACRA makes it easy to game the system

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?