Dr. Michael Kitchell initially welcomed the federal government鈥檚 new quality incentives for doctors. His medical group in Iowa has always scored better than most in the quality reports that Medicare has provided doctors in recent years, he said.
But when the government launched a new payment system that will soon apply to all physicians who accept Medicare, Kitchell鈥檚 McFarland Clinic in Ames didn鈥檛 win a bonus. In fact, there are few winners: out of 1,010 large physician groups that the government evaluated, just 14 are getting payment increases this year, . Losers also are scarce. Only 11 groups will be getting reductions for low quality or high spending.
鈥淲e performed well, but not enough for the bonus,鈥� said Kitchell, a neurologist. 鈥淢y sense of disappointment here is really significant. Why even bother?鈥�
Within three years, the of care to be considered in allocating nine of every 10 dollars Medicare pays directly to providers to treat the elderly and disabled. One part of that effort is well underway: based on excess readmissions, patient satisfaction and other quality measures. Expanding this approach to physicians is touchier, as many are suspicious of the government judging them and reluctant to share performance metrics that Medicare requests.
鈥淲ithout having any indication that this is improving patient care, they just keep piling on additional requirements,鈥� said Dr. Mark Donnell, an anesthesiologist in Silver City, N.M. Donnell said he only reports a third of the quality measures he is expected to. 鈥淪o much of what鈥檚 done in medicine is only done to meet the requirements,鈥� he said.
The new financial incentive for doctors, called a , allows the federal government to boost or lower the amount it reimburses doctors based on how they score on quality measures and how much their patients cost Medicare. How doctors rate this year will determine payments for more than 900,000 physicians by 2017.
Medicare is easing doctors into the program, applying it this year only to medical groups with , including doctors, nurses, speech-language pathologists and occupational therapists. Next year the program expands Medicare to groups of 10 or more health professionals. In 2017, all remaining doctors who take Medicare鈥攁long with about 360,000 other health professionals鈥攚ill be included. By early in the next decade, 9 percent of the payments Medicare makes to doctors and other professionals would be at risk under a bill that the House of Representatives passed in March.
The quality metrics used to judge doctors vary by specialty. One test looks at how consistently doctors keep an accurate list of all the drugs patients were taking. Others track the rate of complications after cataract surgery or whether patients received recommended treatments for particular cancers.
There are more than 250 quality measures. Groups and doctors must report a selection 鈥攇enerally nine, which they choose 鈥� or else be automatically penalized. This year, 319 large medical groups are having their reimbursements reduced by 1 percent because they did not meet Medicare鈥檚 reporting standards.
Physicians who do report their quality data fear the measures are sometimes misguided, usually a hassle and may encourage doctors to avoid poorer and sicker patients, who tend to have more trouble controlling asthma or staying on antidepressants, for instance.
Dr. Leanne Chrisman-Khawam, a primary care doctor in Cleveland, said many of her patients have difficulty just getting to follow-up appointments, since they must take two or three buses. She said those battling obesity or diabetes are less likely to reform their diets to emphasize fresh foods, which are expensive and less available in poor neighborhoods. 鈥淵ou鈥檙e going to link that physician鈥檚 payment to that life?鈥� she asked.
Dr. Hamilton Lempert, an emergency room doctor in Cincinnati, criticized one measure that requires him to track how often he follows up with patients with high blood pressure.
鈥淢ost everyone鈥檚 blood pressure is elevated in the emergency department because they鈥檙e anxious,鈥� Lempert said. Another metric encourages testing the heart鈥檚 electrical impulses in patients with non-traumatic chest pain, which Lempert said has led emergency rooms to give priority to these cases over more serious ones.
鈥淚t鈥檚 just very frustrating, the things we have to do to jump through the hoops,鈥� he said.
In their first year doctors are affected by the program, they can choose to forgo bonuses or penalties based on their performance. After that, the program is mandatory. This year, 564 groups opted out, but even if all of them had been included, only 3 percent would have gotten increases and 38 percent would have seen lower payments, mostly for not satisfactorily reporting quality measures, Medicare data show.
Smaller groups and solo practitioners are even less likely to report quality to the government. 鈥淭he participation rates, even though it鈥檚 mandated, are just really low,鈥� said Dr. Alyna Chien, an assistant professor at Harvard Medical School. It鈥檚 鈥渁 level of analytics that just is not typically built into a doctor鈥檚 office.鈥�
Dr. Lisa Bielamowicz, chief medical officer of The Advisory Board, a consulting group, predicted more doctors will start reporting their quality scores when the prospect of fines is greater. 鈥淭hey are not going to motivate until it is absolutely necessary,鈥� she said. 鈥淚f you look at these small practices, a lot of them just run on a shoestring.鈥�
This year鈥檚 assessments of big groups were based on patients seen in 2013. A total of $11 million of the $1.2 billion Medicare pays doctors is being given out as bonuses, which translates to a 5 percent payment increase for those 14 groups getting payment increases this year. That money came from low performers and those that did not report quality measures to Medicare鈥檚 satisfaction; they are losing up to 1 percent.
The exact amount any of these groups lose will depend on the number and nature of the services they provide over the year. This year, 268 medical groups were exempted because at least one of their doctors was participating in one of the government鈥檚 experiments in providing care differently.
Officials at the Centers for Medicare & Medicaid Services declined to be interviewed about the program but said in a prepared statement that they have been showing their quality and costs. 鈥淲e hope that this information will provide meaningful and actionable information to physicians so that they may improve the coordination and integration of the health care provided to beneficiaries,鈥� the statement said.