A Country Doctor Writes:

My clinic belongs to an Accountable Care Organization. My job is to keep my patients medical costs down, in my clinic as well as in the hospital and specialist offices, without sacrificing quality. Of course, I have about zero control over costs generated outside my office.

So, since I can’t do very much about what Cityside Hospital and all the specialists they employ charge for their work, my only chance of getting any “shared savings” is to make my patients look real bad.

That is what some of the Medicare Advantage plans (Federally subsidized for profit contractors who manage Medicare subpopulations that get extra benefits, like glasses and gym memberships, in exchange for Prior Authorizations and other forms of rationing). I used to puzzle over why they paid us $150 just to update/verify my patients problem lists until I got caught up in the same situation through no fault of my own. Now I also know why these lists sometimes contained outrageously erroneous diagnoses such as paraplegia.

The baseline cost, from which any savings (shared savings for my clinic) or the dreaded opposite is calculated, is predicated on complex actuarial formulas, summarized in what Medicare calls Hierarchical Condition Categories.

This is how that works:

Even through Medicare paid for patient X’s medical care in previous years, and received bills with all of his terrible diagnoses listed, they calculate my base “cost” only counting the diagnoses submitted recently. If they don’t see anything that looks expensive, they budget about $8,000 for the coming year for that patient. Never mind that he is a quadriplegic amputee (which I might not include as a reason for any particular visit, although I might treat and code for his bedsores). Of course, since he may need a new power wheelchair anytime, I wouldn’t want that cost to drag down my “performance”, so I’d better put “quadriplegia” and “below-the-knee amputation” on at least one superbill every year.

It seems obvious they hope I’ll forget to “take credit” for how sick Mr. X really is, so that his multiple hospitalizations and new power chair will hurt my clinic’s bottom line.

In other cases, it is more a matter of word choice: If somebody has fairly stable heart disease and takes nitroglycerin two or three times per year, “coronary artery disease” gets me no points, whereas “angina pectoris” jacks up my baseline a little.

Obesity is an interesting problem. If a patient is morbidly obese, that gives me more of this HCC “play money” to work with. Once they lose the weight, I will of course lose those dollars. But there are quality bonuses to be gained from treating obesity. However, Medicare will REJECT any and all claims for office visits conducted solely for the purpose of treating obesity.

There is obviously more money to be made, at least for the next several years, from aggressive coding than from looking over the shoulders of hospitalists and specialists. I can’t even tell from the hospital reports exactly what they did and why they did it. So how and why could I gain more from that than from becoming a Hierarchical Condition Category Coding expert?

This is what I not so fondly call Metamedicine.

(See also https://acountrydoctorwrites.wordpress.com/2014/07/24/medicine-is-easy-but-metamedicine-is-hard/. The diagnosis codes in that post are the old ICD-9 ones, but the principles still apply.)

Clinical guidelines are a mixed blessing. Wise clinicians know that they offer a general pattern of doing things that usually results in favorable outcomes. They also know there are lots of situations when guidelines can’t be applied because of unique patient characteristics.

Guidelines can be dangerous if we apply them indiscriminately. Education and experience teaches us when and when not to follow them.

The problem with guidelines is that people without our knowledge or experience have placed themselves in positions where they judge physicians by whether we follow a particular guideline or not. Never mind that there are competing guidelines, and that the web repository of them shut down a month ago.

That reminds me of a colorful Swedish analogy my grandmother often used, “som fan läser Bibeln”, translated “like Satan reads the Bible”.

One of many American Christian authors writes about it this way:

“What makes Satan happy is when he can get Christians to believe that Proverbs 15:6 justifies the accumulation of wealth in a world of hunger; that 2 Thessalonians 3:10 abolishes charity; that Romans 9:16 makes evangelism superfluous; that 1 Timothy 2:4 means God is not sovereign in conversion; that John 10:28 means a “Christian” can do whatever he wants and still be saved; that Hebrews 6:4–6 means there is no security and assurance for God’s elect.”

If Satan can pick and choose Bible phrases to confuse, tempt or mislead earnest and well meaning Christians, imagine what someone with ill will or authority without wisdom can make out of clinical guidelines.

That is the reality of today’s Quality Quagmire in health care.

We sometimes get judged if we don’t have diabetics on ACE inhibitors, even if they don’t have microalbuminuria. According to UpToDate, there is insufficient evidence for this practice.

Regarding statins, the American College of Cardiology writes: “Five major North American and European guidelines on statin use in primary prevention have been published since 2013. Guidance on use in the growing elderly population (age >65 years) differs markedly…The main goal of primary prevention with statins is to achieve net-benefit from treatment. Potential harm(s) is a crucial part of appropriate decision making. As frailty, comorbidity, and polypharmacy may increase the risk for adverse statin-associated symptoms, the “risk-benefit” balance in the elderly could theoretically tip in favor of withholding statin therapy if such conditions are present.” So much for following guidelines there.

Another striking example of how crazy this system is:

A doctor sees a patient with bronchitis. Guidelines discourage antibiotics. That is a Quality indicator. On the way out of the office, empty handed, so to speak, with no antibiotic but a lengthy diatribe about the uselessness of antibiotics and the looming threat of multi resistant superbugs, the patient is asked to rate his physician. Such ratings are an increasingly large part of provider evaluations and even compensation formulas. Will that patient give the doctor a favorable rating?

This what I do: Some patients, like those with chronic lung disease, get antibiotics right away. Others get a thorough explanation of why I’m not prescribing them. And a few get a “backup prescription”: “If this, this or this happens, fill it”.

Guidelines and doctor ratings shouldn’t tie our hands. We are the professionals here. We must apply our knowledge to every clinical situation we encounter. In some cases, the people who dangle guidelines or popularity ratings over our heads are simply being ignorant bullies.

The Family Doctor used to be almost the only source of medical information patients had access to. Now, few people need us to bring them the latest news. It’s there for everyone to see. There’s even too much of it.

Today, our role is to help make sense of it all. In order to do that, we must possess and project authority, but we have no reason to put ourselves on any kind of pedestal.

In our culture, evidenced by the stories we read, the movies we watch and many of the ways we interact with the world, people see themselves as heroes of their own lives, the main actors in their own narratives. Most Westerners aspire to reach higher levels of skill, status, health or wealth. We, deep down, generally don’t connect well with heroes who are flawless and obviously much better than we are, and we identify the deepest with products, companies and professionals who help us move toward our personal goals.

Today’s business literature urges entrepreneurs and business leaders to take on a supportive role rather than flaunt their achievements or expertise. “Be the Guide, Not the Hero” is a quote from Donald Miller of StoryBrand.

The dominating narratives present a flawed, insecure hero, who faces challenges while also reaching a higher level of insight, and he or she is supported by a guide who is older or wiser (Obi-Wan Kenobi or Yoda) but in no way competing with the fledging hero. These characters have been there, done that, and have nothing to prove. They are portrayed in ways that indicate they are supremely competent and yet almost self effacing. It is not their turn to shine.

That is a useful way for doctors to think of themselves. We must support our patients in their own pursuit of health and happiness. They must find out or choose for themselves. We can not make them do things that they don’t see or feel by themselves. And we have no right to expect that they will always follow our advice.

Our quality metrics can make us feel as if we are the main characters, or heroes in the story analogy, in our interactions with our patients. The results of our efforts can make us feel as if we are experiencing success or failure. This in turn can create job stress and burnout.

By adopting and staying in the role of Guide, physicians can preserve their stamina and enthusiasm for each and every patient encounter. We offer guidance, but every hero is free to choose whether or not to accept our words of wisdom.