Robert B. Doherty, BA
Acknowledgment: The author thanks Shari M. Erickson, MPH, and Kolton Gustafson.
Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-0992.
Requests for Single Reprints: Robert B. Doherty, BA, American College of Physicians, 25 Massachusetts Avenue NW, Suite 700, Washington, DC 20001.
Author Contributions:Conception and design: R.B. Doherty.
Analysis and interpretation of the data: R.B. Doherty.
Drafting of the article: R.B. Doherty.
Critical revision of the article for important intellectual content: R.B. Doherty.
Final approval of the article: R.B. Doherty.
Administrative, technical, or logistic support: R.B. Doherty.
Collection and assembly of data: R.B. Doherty.
Doherty RB. Goodbye, Sustainable Growth Rate—Hello, Merit-Based Incentive Payment System. Ann Intern Med. 2015;163:138-139. doi: 10.7326/M15-0992
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Published: Ann Intern Med. 2015;163(2):138-139.
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Michael E. Miller, M.D.
Boston University Affiliated Physicians
August 26, 2015
As usual Robert Doherty’s clear-headed analysis and writing conveys, in most understandable fashion, the vital aspects of issues involving the nexus of physicians and the federal government, in this case the coming Merit Based Incentive Payment System (Goodbye, Sustainable Growth Rate…Annals, 21 July 2015). I am most concerned with the explicit warning in his last paragraph: “…physicians must advocate to ensure that the MIPS and APMs measure the right things, do not add to administrative burdens…a tall order.”Historically, physician advocacy efforts on these types of issues has, in my opinion, been poor. The development and utilization of electronic records as primarily billing, coding and physician grading systems requiring endless hours (time better spent with patients) of tedious data entry instead of facilitating patient care was a direct result of the absence of effective physician advocacy. The morphing of HIPPA from patient protection and privacy to an impediment to the rapid interchange of important clinical information, an administrative burden dumped on physicians, and a “free ride” for insurers who essentially exempted themselves (via the claim of “health care operations”) from most of the act’s obligations also resulted from lack of advocacy. The fact that so many primary care physicians are employed by large institutional providers means that the nature of the contractual terms of the MIPS program will be negotiated between the federal government and the institutional providers (who will advocate for themselves), not their employed physicians. The persistent presence of aggravating, time consuming, and often devoid of clinical utility prior authorizations for imaging procedures, medications, and additional day to day clinical operations reflects ineffective physician advocacy. It is worrisome that these burdens actually seem to be increasing. My practice’s experience with quality metrics reporting has been frustrating; disparities between insurance claims data and our internal practice data has resulted in more time demands poring over spreadsheets and data bases, and the expense of hiring additional staff. Of course we continue to argue (futilely) over the clinical appropriateness of arbitrarily chosen metrics to determine what makes a good doctor. Physician based advocacy has been meager.So, despite the welcome expiration of the flawed Sustainable Growth Rate, I have little confidence that effective physician advocacy will shape the coming new physician payment system. Can Bob Doherty (hopefully) change my mind?
Robert B. Doherty, BA
American College of Physicians
February 24, 2016
I appreciate Dr. Donohoe's observations about academic medical centers that sponsor "concierge" clinics. He is correct that our paper did not specifically address academic medical centers; rather, we looked at the broader movement to practices that charge retainer fees, do not accept insurance, and/or limit the numbers of patients they see. (We called such practices direct patient contracting practices, or DPCPs, because of the lack of any consistency in the commonly used descriptions in the literature of "concierge" practices). I agree that attention needs to be paid to the ethical, educational and patient care implications of academic centers who operate such practices and on their potential impact on the poor.However, our paper does provide a policy framework for evaluating any practice that has one or more of these 3 features, which can include academic medical centers. We state that "Physicians in all types of practices must honor their professional obligation to provide nondiscriminatory care, serve all classes of patients who are in need of medical care, and seek specific opportunities to observe their professional obligation to care for the poor"; this would include physicians in academic medical centers who operate concierge clinics. We advocate that physicians consider the potential impact of changes in their practices that could make it more difficult for poorer patients to access medical care and to consider steps to mitigate any such impact. We note that there is some evidence that concierge practices are at a greater risk of excluding poor and other vulnerable populations, although we also note that there are examples of direct primary care practices (one variation of concierge medicine) that the literature shows have structured themselves to provide accessible, low-cost care to the poor including patients enrolled in Medicaid. We conclude that "Although the growing physician interest in DPCPs may be an understandable reaction to such external factors, it must also be recognized that such models potentially exacerbate racial, ethnic and socioeconomic disparities in health care and impose too high a cost burden on some lower-income patients."We agree with Dr. Donohoe that there is little in the way of high quality evidence on the quality of care or the clinical- and cost-effectiveness of the "extra" services often offered by concierge practices. Because of the lack of good evidence on this and other effects of such practices, we propose a robust research agenda. We especially endorse the need for research on "the impact and structure of [such] models that may affect their ability to provide access to underserved populations." I do think it is important that as we research and consider the policy and ethical implications of concierge practices, we also consider the external factors that are driving many physicians toward them--including excessive paperwork associated with insurance interactions, EHRs that are designed to meet the needs of payers and regulators and not the clinical needs of physicians and their patients, and productivity-based payments that penalize physicians for spending more time with their patients. I have met many physicians who have gone into concierge and direct primary care practices precisely because they want to get back to doing what they love most, which is spend time with their patients. Many say they charge very low monthly fees so that they can be accessible to moderate and low-income patients, at less out-of-pocket cost to the patients than can be found under many high deductible insurance plans. I would caution about painting too broad a brush in assessing the motivations of, and impact on poorer patients, of physicians in practices that charge retainer fees or limit the numbers of patients they see. Rather, we need more unbiased research and evidence--while strongly reminding physicians, as we do in our paper, of their ethical obligations to provide care that is non-discriminatory based on a patient's income, gender and gender identity, sexual orientation, race or ethnicity--no matter what type of practice they are in, concierge or not.
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