Feet First

“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” - Sir William Osler

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    Sunday, November 11, 2007

    I needed this vacation badly; fatigue has been my watchword lately, it seems. The summer flew by unnoticed taken up mostly by work (even more so than usual). What with our EMR (electronic medical record) project, my partner taking three weeks' vacation and the looming "pay for performance" deadline the last two months have been completely insane.

    I hope the rest of 2007 will be better: now it's MY turn for vacation, I have very few meetings scheduled for the next month and I finished reviewing my P4P list, so at least that's off the table. P4P, or "pay for performance," is one of those bureaucratic chores that make primary care doctors' lives so much fun. Insurance companies love to dream up highminded ways to improve care; if they incidentally make the practice of medicine more difficult in the process, that isn't their problem. The premise behind P4P is that doctors who give good care should be rewarded with higher pay, which seems reasonable. How do you know which docs give "good care"? - the ones who do the most mammograms and Pap smears, of course. Not to mention keeping the cholesterol and glycated hemoglobin levels of their diabetic patients within certain mandated boundaries. It's all about managing chronic illnesses these days.

    This sounds logical, but the stumbling block here is trying to keep track of the patients who don't get their mammograms (or other screening tests) and don't come to the doctor. Most do, of course. I think most patients want to stay healthy. But if one of my patients has decided that mammograms are too painful an ordeal and she doesn't want to do them, it not only puts her health at risk, her decision now reflects on me. With enough noncompliant patients I get pushed down below the benchmark level (and this information gets published in local and national media, so it matters) and I may now be faced with a pay cut if my patient statistics don't meet the benchmarks set by the all-knowing insurers. Insurance companies pay a bonus of anywhere from two to, I think, ten or twelve cents per patient signed with the group if you meet their benchmarks. If you have thousands of patients signed up that means a lot of money is at stake. If we don't meet the benchmarks the group doesn't get the money and the doctors within the group who didn't get their patients' cholesterol (or other clinical care marker) controlled will be financially penalized.

    This means that I usually spend the last few months of the year frantically tracking down patients to get them scheduled for studies. I have patients on my list whom I have never seen who have been assigned to me for years. They may live out of area, or they may be seeing another doctor on their spouse's insurance - it doesn't matter, if they are assigned to me I am responsible for them, and if we don't have their data I get dinged.

    A while back I got an email from a patient with the title "Why are you disenchanted, Doctor?" She genuinely wanted to know. I emailed her back thanking her for writing and telling her that while I loved the practice of medicine, there are bureaucratic aspects to it these days that are making it less and less fun and told her that I planned to write about those issues. This is an example of what I meant.

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