Thursday, January 31, 2019

The Cure for Checkbox Medicine: Physician-Led Clinically Integrated Networks

Years ago, I was contacted by a health plan about an elderly nursing home patient who had not been screened for osteoporosis.

While brittle bones are a big problem in skilled nursing settings, the real problem for this health plan was its low HEDIS score for “osteoporosis testing and management.” Because of the underlying financial stakes and the marketing advantages that come from claiming a “number one” spot in quality, the health plan nurse wanted me to order an “osteoporosis screening test.”
This is a classic example of checkbox medicine run amok. It their zeal to promote health care quality, payers, regulators, politicians and academics have meddled in the doctor-patient relationship with requirements promoted by HEDIS, the Stars Program, MACRA and other “performance assessment tools” that are often disconnected from the complexities of real-world care. In the instance of the patient above, she had already been diagnosed with the condition (so no screening was necessary) and she had multiple contraindications to treatment.

This made little difference to the health plan, which had created an entire department dedicated to tracking down every care gap. As their complexity and numbers grow, physicians are being hassled with quality metrics that are process-based, statistically suspect, non-transparent, burdensome to report and of questionable value to patients or society. This is not just a distraction, but a huge cost to physicians and ultimately their patients.

Fortunately, there is an innovative cure for this problem. Physician-led clinically integrated networks (“CINs”) are safe harbors for quality programming that are an alternative to checkbox craziness. These types of CINs are created to engage in value-based care arrangements with insurers; these “VBC” compensation models are gradually replacing standard fee-for-service and are an important opportunity for any physician who has been struggling with check-box health care:

1. Physician-led CINs can negotiate terms that transfer ultimate responsibility for quality metrics from the “payer” to the “provider.” As these CINs develop their own workflows and hire their own personnel, physician oversight makes it far less likely that a colleague will be hounded by a well-meaning if clueless quality improvement nurse.

2. Physician-led-quality programs are not configured specifically for HEDIS but are likely to benefit HEDIS. In other words, as a CIN creates the policies, procedures, metrics, workflows, reporting and feedback loops for the management of chronic conditions, that rising quality tide will also benefit the HEDIS boat, and their measures will increase. It's care, not care gaps.

3. Health plans are burdened by dozens of quality measures imposed by employers and government, which, unfortunately, results in everything being so important that nothing is important. Physicians understand the virtues of setting priorities. When this is combined with their awareness of what matters most to their patients, CINs can negotiate limitations on the number of quality metrics. What can follow is real improvement.

4. Finally, while HEDIS and similar programs have been carefully developed over the years by considerable numbers of experts, health care quality is a rapidly moving target. Physician-led CINs can partner with enterprising health insurers and employers to rapidly develop and deploy new quality metrics using a classic “plan-do-study-act” (or PDSA) approach. One area of opportunity is in the area of social determinants of health.

Many of my physician colleagues love to hate their insurers’ quality programs. Many will continue to write understandably angry editorials or compelling narratives or stirring resolutions (see 108) or public calls to just say no.

Unfortunately, despite their many limitations, quality programs like HEDIS as well as value-based care are here to stay and has overwhelming bipartisan support. Fortunately, physician-led CINs using the four innovative approaches above offer a far more viable alternative. It’s up to physicians to seize that opportunity.

This post was originally published on KevinMD of MEDPAGE; the blog is social media's leading physician voice. Jaan Sidorov is an internal medicine physician and CEO and president of the Care Centered Collaborative at the Pennsylvania Medical Society.  The opinions expressed above are solely my own and do not express the view or opinions of The Collaborative or of The Pennsylvania Medical Society.  However, hundreds of Pennsylvania physicians like the idea.

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