Evidence based medicine (EBM) has become the mainstay for insurance denials; i.e., the evidence that standard deviations should not be normative and the foundation for why doctors should be automatons in how care is provided before ever thinking about the uniqueness of the patient.  This philosophy is now upon us.

Well, the entire Quality Payment Program (QPP) is driving payment reform and harkening ‘anticipated’ and speculative cost savings by adherence to these clinical metrics. We know it is flawed at its foundation but this is the program with which we must comply. The only demonstrable value to the Merit-based Incentive Payment System (MIPS) lies in the total mitigation of the Sustainable Growth Rate (SGR) that was, frankly, unsustainable. The SGR limited payment to doctors unlike any other healthcare compensatory system in existence in the United States. It’s departure was lauded and welcomed. In its place are EBM and QPP. However, the Centers for Medicare and Medicaid Services (CMS) and the rest of those jumping on board ‘payment reform’ forgot the evidence to prove their system will work.

Clinically there is no EBM that any of this will save money. EBM is the standard for nearly anything being done in US healthcare over the last 10-15 years.  As such, we are involuntarily participating in an in vivo study and the penalty, if it doesn’t work, is on the back of the providers. That said, the PQRI-Physician Quality Reporting Initiative began because CMS felt 95% of metrics represented preventable expenditure IF the provider knew how to positively impact care and reduce expense.

With regard to MIPS quality measures and their evolution, what providers think they are doing (or their patients experiencing) is not always reality. An early client of P360 was an internist who came to us furious with his practice manager because data demonstrated only 60% of his diabetics were getting HgbA1cs.  He was certain he did them for all his diabetic patients.  P360 queried his entire database of patients and found 40% of diabetics under his care not having the test.  He again insisted he did them 100% of the time. He was right. The 60% of the patients he physically saw in the office received the test but the other 40% were not seen by him. Instead they were noncompliant either receiving care in another place of service (e.g., ER or urgent care centers) or not at all.

Providers don’t know what they don’t know. They can’t affect change on the unknown. MIPS will fail if practices cannot access data on all patients for which they are responsible and the practices currently are not linked nor set up to do so. It’s paramount registries like P360 prevent payers from retaining money for work the provider could/should have done. If no clinical reporting occurs, in real time over the course of the year, how can a provider know to modify his/her clinical work product and/or reach out to patients they assumed were being well-managed? How can there be evidence if providers don’t have clear analytics?

The same goes for the “new” MIPS categories for Improvement Activities (IA) and Advancing Care Information (ACI) measures. The IA and ACI metrics are very similar but require an EMR that fully engages the practice with pragmatic usability based on provider workflow.  Most EMR QPP metrics are drawn up and written by programmers, not doctors. A recent article in Healthcare Finance News titled ‘EHRs Eating up Half of Doctors’ Workday with Unpaid Labor’ shows that docs spend literally half their day in their EMRs not taking care of patients. This is not just an article bemoaning doctors being overworked, but a practical look at this in vivo study demonstrating how EMRs and new reporting is diminishing patient care, not enhancing it.

This is a paramount issue to conceptualize for those writing policy or orchestrating reimbursement to conceptualize. Having an EMR that does the reporting DOES NOT mean it is easily done AND it cuts into clinical work expectations (economic and quality of care) when clinicians cannot see the patients they are expected/need to see. Moreover, and a major ethical dilemma for docs is that patient access goes down since the clinician cannot physically see them… not enough hours in the day. Doctors, NPs, PAs, and all other clinicians invested countless hours and monies in education and training so they could take care of patients.

Working with a QPP registry like P360 will optimize reporting while limiting the burden too many feel especially when they don’t understand how to maximize clinical performance and patient experience through easier data extraction/analysis. And, when QPP and other outcomes’ reporting are done well, elevated compensation is a tremendous and desirable by-product.