SPEAK YOUR MIND If you would like to respond to an article in this issue, please submit an article or letter to the editor. Contributions may be sent to editor @ glms. org or may be submitted online at www. glms. org. The GLMS Editorial Board reserves the right to choose what will be published. Please note that the views expressed in Doctors’ Lounge or any other article in this publication are not those of the Greater Louisville Medical Society or Louisville Medicine.
NOTE: Due to the intensity of the current political environment, we remind readers that this section( Doctors ' Lounge) is reserved for unadulterated opinion. The following articles are not the opinion of GLMS. Its important for members to have open, insightful dialogue and debate on issues far and wide. If you are stirred by any article, whether in agreement or disagreement, please respond with a letter to the editor.
THE NEWEST LEPERS
Mary G. Barry, MD
Louisville Medicine Editor editor @ glms. org
Under the terms of MACRA, the 2015 Medicare Access and CHIP Reauthorization Act( the new improved lemon-freshened value-based Medicare redesign that replaced the SGR), patients who make their doctors look bad on the performance measures may one day find themselves joining the Untouchables caste.
Doctors( and APRNs and PAs and others) will be reimbursed by Medicare based upon a complex formula that takes into account how cost-effective was the care they delivered, and how well that care met“ quality” goals. I wrote about this formula two years ago, aghast that patient-dependent variables such as adequacy of diabetic control – rather than measurement of diabetic control – might be included. Physician / NP / PA reimbursement will rise- or drop- compared to each one’ s score amongst his or her specialty group;“ primary care” includes lots of us, not just internists.
We can’ t all have practices full of triathletes. What will happen to the average overweight, sedentary American who also works and helps to raise grandkids and has poorly, but not horribly, controlled diabetes? His Hemoglobin A1C( a three-month measure of blood sugar control) and her triglycerides, and certainly their body mass indices, will fall outside the desirable levels. How soon will the doctors who care for them begin to eye them speculatively as potential financial risks? Currently only an A1C of more than nine is an outlier. Weight and lipid management are being considered for core measurement status, but have not yet been chosen. If I were a bureaucrat though I’ d be on that bandwagon, since all relate to cerebral and cardiovascular health.
What will happen to the smokers? So far, substance abuse has not made the cut as a core measure in and of itself, but patients will be rating us on our“ Health Promotion and Education” efforts, and our“ Shared Decision Making” during their visits. So far, we are not being held accountable for the percentage who quit smoking, but we will be held accountable for their increased use of resources. For instance, antibiotic use in acute bronchitis will be penalized, their ER visits will be scrutinized, and our prescribing of imaging and specialty consultation will be noted, with points added or deducted to our“ scores.” How long will smokers’ tenure last with doctors who have long since tired of preaching against tobacco?
What will happen to the disabled? Lots of them live in wheelchairs, on limited incomes, with large medical and personal care expenses. Buying very expensive insulins comes in low on their lists of necessities; buying incontinence pads matters more. What will happen to the illiterate, to the homeless, to the mentally ill? What will happen to the people who only believe in shark cartilage and consequently have LDLs of 200 and blood pressures of 170( taken no doubt by the ubiquitous and erroneous machines, not a trained doctor with a proper cuff)?
What will happen to the long-term cancer survivor, the owners of artificial valves and fibrillating hearts and sleep apnea machines, the arthritic, the immune-suppressed and the immune-beset, whose autoimmune diseases require biologic therapies that cost the earth? What will happen to the catastrophic illness survivor who is still needing therapy months and months later? When their doctors retire, what young buck will want to take on such a medical and financial
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