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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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