Breaking the Code ~ by Jay

Lauredhel informs us that the AMA considered (and reportedly defeated) a resolution to investigate a code for non-compliance.

(The fact that an American doc learned about this from an Australian blogger will simply be ignored for the moment. And I'd have commented there but WordPress won't let me sign in)

So what's the big deal?

The comments at Hoyden are pretty clear about what the big deal is. If you're coded as non-compliant, what then? Does your coverage get terminated? Since when is non-compliant a diagnosis? The commenters are justifiably enraged at being blamed for not following a doctor's instructions, as if everything the doctor said was handed down at Sinai.

The resolution also lumps "non-compliant" with "abusive and hostile". Lots of people can't or don't do precisely what the doctor asks. Most have perfectly good reasons for that decision - the medication makes them sick, or they can't afford it, or they don't have time to do physical therapy, or their insurance doesn't cover that testing. I suppose a lot of people are "hostile", but when I'm not feeling well and I'm confronted by an impenetrable bureaucracy, I'm usually kind of hostile, too. Very few patients are actually abusive. We need to protect ourselves from truly abusive or threatening behavior, but we shouldn't lump that in with reasonable responses to outrageous stresses.

So what's up with the AMA? Entitled, whiny, doctors with their heads up their assess and their privilege threatened? Partly. I do understand the outrage, and I'm glad the resolution was defeated. I also see a less whiny motivation, though. Insurance companies are holding docs completely responsible for what patients do and don't do, and docking our pay if the patient doesn't follow through. It's called pay for performance, and it's seriously fucked.

Pay for performance sounds like a good idea on the surface: reward the doctors who practice evidence-based medicine and provide care that matches best practices. Since we're capitalists, the "reward" is money, of course. The fucked part comes in how the measurement is done. Standard recommendation: everyone with diabetes should see a podiatrist and an ophthalmologist annually. Everyone with diabetes should have a cholesterol level measured annually. Everyone with diabetes should have their blood sugar at goal. The insurance company used to check to make sure we made the correct recommendations, but now it's pay for PERFORMANCE, see? So the insurance company takes every patient of mine with a diagnosis code for diabetes and checks their records to make sure they also have claims for that patient from the podiatrist, the ophthalmologist and the lab. Then they check my chart to make sure the results are in order. If all the little boxes line up, they pay me some extra money.

But what if the podiatrist's office screws up and doesn't submit the claim? What if the patient is working nights and can't get to the ophthalmologist? What if her blood sugars were in the 300s last year and now they're much better but still not quite at goal?

Doesn't matter. No PERFORMANCE. No cookie for me.

That's no big deal when it's extra money, but it becomes a big deal when it's tied to basic reimbursement (which is already dropping for most of us in the US) and when it's expanded to treatment for hypertension, heart disease and other common ailments. It's a big deal when it's happening at the same time that our patients are losing their insurance or facing much bigger deductibles and copays, making it harder to get to the specialists and the lab.

I'm in favor of evidence-based medicine and practice guidelines. I don't think it's wrong for entities like hospitals and government agencies and even insurance companies to help docs distill information and provide good care. I think physician autonomy has been taken to an extreme in the US, and that the AMA has supported physician autonomy and greed at the expense of our patients. I will never join the AMA; this resolution did nothing to help us work with patients to overcome barriers to getting the care they need. I think they acted out of fear and frustration and, yes, a fair amount of whiny privilege. But I do understand where the fear and frustration came from. There has to be a better way, for all of us.