Primary care doctors have had enough. I’m sick of it as a family physician, and I know you are too. In our never-ending battle with insurance companies and CMS bureaucrats over how to do our job, the new turf is value-based care (VBC), and the latest weapon against us is metrics.
The central goals of VBC are timely access, better care quality, and efficiency. One could argue if achieving all 3 of these goals is even realistic for health care. Consider the oft-cited quote within the construction industry: “Good, cheap, fast- pick 2.” If we cannot accomplish all three of those goals in building and restoring homes, why do we think we can accomplish them in building and restoring our bodies?
Yet, that is the barking mandate from the insurance industry and CMS. I have yet to see one developed country that successfully reaches all of these goals. For this strategy to be successful, insurance companies and CMS must exert an exceptional level of control over several aspects of care delivery. Thus, value-based care mainly targets the actions of that one specialty in medicine that gets the most traffic- primary care. As the name implies, primary care is the entry point for most patients into the system, and the primary care doctor is the quarterback of their ongoing care. When most patients establish care with a primary care doctor, they do so with the intent that it will be a long-term relationship. They expect their doctor will be with them through the ups and downs of life and help them with the inevitable medical challenges. Historically, the crown jewels of primary care have been trust, communication, and empathy. Doctors like myself who chose primary care in medical school did so because we enjoy getting to know our patients and their families and being a part of their lives. Studies show that trust, compassion, and empathy are positive predictors of better health outcomes. But developing these relationships takes time and relational time has no value to an insurance company.
The assumption is that, if primary care doctors meet these various metrics, we will achieve the triple aim of improved patient access, lowered care costs, and improved quality of care. Some of these, like periodic A1c tests for patients with diabetes, make sense, as it ensures accountability and appropriate patient care. However, what we have is an outrageous list of metrics heaped onto primary care doctors, in what some have called “metric fever.” Currently, there are over 90 metrics spread across six areas of care, many of them falling within the purview of primary care. Fulfilling these requirements is extremely resource-heavy. We need to hire “population health” teams to help us stay abreast of the ever-changing rules and help manage these metrics’ documentation. The focus of the patient’s visit has now shifted from the patient to a list of boxes to check. For primary care doctors who are relational by nature, this is a violation of a sacred space.
Moreover, it is an incredibly time-consuming process. One study showed that for every hour spent in direct patient care, two hours is spent inputting that data into the EHR. To be clear, we should have quality assurance measures in health care as we do in many other industries. But we need solid evidence that this death by a thousand metrics is actually measuring quality. Do we really need 90 metrics to know if Americans are getting good care? In the daily grind of checking boxes, at what point is the primary care doctor reduced to a bean counter for the insurance company? At what point does the patient stop being an individual and become a transaction? There is only so much time you can spend with each patient, and the insurance company only cares about which metrics you fulfilled. They don’t read a patient’s note to understand the complex medical conditions of a patient. To the insurance company, Mrs. Smith is not a person, she is a compilation of diagnosis codes, and each of those codes needs to meet the corresponding metric goal set by the insurance company or CMS. The assumption is that if a patient’s data set is missing what they want to see, you didn’t provide adequate care.
Physicians didn’t go to diagnosis code school. Yet we are expected to be fluent in the language of the insurance company and the National Committee of Quality Assurance (NCQA) to get paid for the work we do. As policies like value-based care keep rolling out, the language is getting more and more complex. We must spend more time learning the language and less time talking to our patients. Here’s a maddening example: I have a patient with hyperlipidemia, managed by her cardiologist. She is on Repatha because she can’t tolerate statins. I get dinged for the “care gap” of her not being on a statin with her diagnosis of hyperlipidemia. No matter that I am not even managing it and that her hyperlipidemia is being addressed with Repatha. The insurance company’s proposed solution: I need to make sure to document the diagnosis code T46.6X5A, “intolerant to statins” on a yearly basis to avoid financial punishment. This system of metrics has enabled the insurance overlords to hijack our profession into a documentation nightmare.
The constant financial threat of not meeting these quality metrics and the administrative costs associated with them have been major factors in two very concerning trends in primary care. Tired of the insurance hamster wheel, many physicians have chosen to either leave primary care or retire early. Larger health care entities have acquired other primary care groups as they can no longer financially stay afloat on their own. As of 2021, 70 percent of U.S. physicians are employed by hospital systems or other corporations. Approximately 30 percent remain as independent physicians. This lopsided employment of physicians is not a good thing. The more doctors that hospitals or insurance companies own, the more market share they command, which means higher costs of care. In 2019, Optum, a subsidiary of United Healthcare, bought Atrius Health, the largest independent physician group in Massachusetts. Optum was already the largest employer of physicians in the U.S. We should not be naïve in interpreting their business strategy as they seek to acquire more and more independent physician groups. As independent physicians are getting squeezed under the weight of value-based care requirements, acquisition becomes the Hobbesian choice.
Value-based care may not be a bad idea as a concept. It solves the What? The hard part is the How? The immense burden of administrative tasks that VBC forces onto primary care doctors cannot be overstated. Since VBC is not going to go away, the only way out of this trap is to massively reduce the patient panel size of primary care doctors. We simply cannot care for 2,000 or 3,000 patients and handle the mountain of oversight and box-checking that goes with it. We cannot be expected to see 20 or 30 patients a day in this model. If value-based care is going to work, we need tens of thousands more primary care doctors. Primary care is the backbone of a robust health care system, yet ours is getting more osteoporotic by the day. According to the AAMC (American Association of Medical Colleges), the U.S. is expected to face a shortage of 21,400 to 55,200 primary care doctors by 2033. We cannot afford to lose any more primary care doctors. If we don’t course-correct and ease the burden on primary care doctors, in our myopic attempt to control costs, metric fever will decimate our primary care workforce well before 2033.
Sara Bajuyo is a family physician.
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