Doctors try to balance care, federal demands
Corrections & Clarifications: An earlier version of this article misspelled the name of patient Tim Layman.
Tim Layman has high blood pressure but stopped taking medication for it more than two years ago because "it's not really for me."
"I believe there is a God that supersedes that natural order," says the Rogers, Ark., pastor. "I’ve been made this way, and I’m not concerned about it."
His doctor is. Mark Miller is worried about his friend and patient's health, but he's also concerned about his bottom line. Soon it will take a hit if the health of patients such as Layman does.
While Washington determines the fate of the Affordable Care Act, a less well-known rule overhauls how doctors get paid and the kind of health care they deliver. The new rule, finalized last fall, replaced a much-criticized formula that put doctors at risk of annual double-digit pay cuts with one that links their payments to the quality of their service.
Prep for the polls: See who is running for president and compare where they stand on key issues in our Voter Guide
Still, it's hardly perfect.
"I can make all the recommendations, but If the patient doesn’t comply, I may not meet the goals," Miller says.
Miller supports the rule, which was part of the Medicare Access and CHIP Reauthorization Act (MACRA), and is part of an effort to improve the quality of care and reporting in his area. He just finds some patients harder to treat than others, even in his relatively healthy area of Fayetteville near the Walmart headquarters. He and a colleague discussed the challenges of one such Medicare patient before a recent interview.
"The downfall of quality reporting is that some patients, because of diet and lifestyle, are going to have more heart attacks," Miller says. "That makes me look worse than the quality of care I’m really trying to deliver to the patient."
At 55, Layman isn't on Medicare but gained insurance when Arkansas expanded Medicaid under the Affordable Care Act. He's emblematic of the challenges Miller faces. Layman has decided to ignore low-fat eating: "Gravy and bacon are back on the menu for me."
"The only concern I have about food is that at 255 pounds, I’m not trying to get any bigger," says Layman, who is 6 feet tall. "I try to moderate how much I intake, but what I intake is of no consequence to me."
Since the ACA's passage in 2010, the Centers for Medicare and Medicaid Services has tried to accelerate the move away from paying doctors and hospitals for the quantity of services to focus more on the actual results. The new rule consolidated several "merit-based" incentive systems into one that reduces the possible penalties doctors face while making them eligible for potentially larger bonuses.
Read more:
Obamacare repeal threatens public health funding to states
Business, community groups boost health partnerships
The vast majority of doctors aren't even sure what the new payment system requires of them, says Tom Giannulli, a doctor who is chief medical information officer of the physician software company Kareo. Miller, one of Kareo's clients, is an exception.
"A lot of them are not clear on why (regulators) are doing it," says Giannulli. "It's for everyone’s benefit and so we can finance Medicare in the future."
MACRA is “a really significant signal to the market...that healthcare is fundamentally shifting," says Jack Stockert, a physician who heads business development for the health care technology company Health2047. The American Medical Association was one of the initial investors in Health2047, which is helping doctors prepare for health care delivery at the century's midpoint.
Doctors, says Stockert, "have always held themselves accountable to delivering the best health outcomes." But the proof in whether they were succeeding was typically anecdotal.
“There is no data on what’s working and what’s not, which is a result of isolated data, messy data, and incomplete data," he says. "This helps move the market in that direction."
'Norman Rockwell painting'
James Walker has practiced family medicine in Washington state and rural Oregon since he graduated from medical school in 1980. It's been a bumpy road for a once-solo practitioner, in no small part because of Washington, D.C.
Walker sold his practice to a hospital in 2010 when it became "totally infeasible from a financial standpoint" to remain independent. That hospital will soon spend about $11 million for the technology needed to meet federal requirements for data and electronic records.
Walker's daughter, Emily Stockert, is an anesthesiologist at Stanford Medical Center, and Jack Stockert, his son in law, works to make the shift to high-tech health easier for other doctors. While he was training to be a doctor, Stockert found it wasn't like the "Norman Rockwell painting" he expected and that he saw in his father in law's enjoyment of the doctor-patient relationship.
"We should all want that In our medicine, in our doctors, in our patient experience," he says.
He hopes helping doctors overcome health IT challenges will make health care more rewarding.
"MACRA causes a shift and drives innovation to begin to show more clearly what is effective," Stockert says. "And by paying for better outcomes, the legislation ensures that decisions that deliver healthier people are rewarded appropriately."
Walker, his father in law, says he would have liked to have seen "a good data test" before the new quality reporting rule "was foisted on the public."
"In 20 years, will there be fewer diabetic foot amputations for all the effort expended?" he asks. "Sometimes the outcomes don't pan out."
Miller, who is on the board of a clinical network of hospitals and doctors offices in his area, tries to stay ahead of quality reporting. He just hired a "care navigator" at his TruHealth Family Care because he sees "the writing on the wall." He expects her to "pay for her salary" many times over, given the effect her work will have on his Medicare payments.
"I’m actually pretty excited about it," Miller says of payment changes. "I'm embracing it because I know it’s the future."