Physicians must take back control over definition of quality in medicine

Guest Post by Cynthia Marcotte Stamer, Esq.

Balanced billing is an important element, but only works if physicians recapture control over the quality question.   That’s why in addition to anything else physicians do, physicians must work to take back control over the right to define quality in medicine by controlling or beating back payer driven, cost motivated PQRS and other quality rankings that demonize physicians for practicing better medicine than what payers want to pay for both by demanding meaningful input to the design and quality standards and processes, pushing for reform that prevents payers and the government from misaligning and punishing physicians that put patients first, and other actions that ensure that patients put their confidence and control of care in the hands of physicians not payers or the government.   CMS recently extended the comment deadline on the 2016 PRQS Quality Measure Plan to March 1.  See CMS Seeks Public Comments on Draft Quality Measure Development Plan (MDP) by March 1, 2016 (1-29-2016). See here.  I urge everyone to review and submit meaningful comments on these proposed quality measures as whether or not you use to participate, they will be used to rate you.

The sad reality is that boycotting or ignoring PQRS and other quality rankings only plays into the hands of government and private payers efforts to marginalize physicians who refuse to play the game by their rules.  Whether inside or out of network, private pay or government, all physicians know that government health program bean counters and insurance payers regularly put dollars before patients by refusing to pay for medically necessary and appropriate care when the payer sees and opportunity to cut costs by declining coverage, while all the while rebranding utilization and cost containment processes that payers once openly admitted were cost-management processes as patient protective “transparency,” “quality” and “fraud prevention” initiatives designed to protect patients from greedy, evil physicians and other health care providers.

As explained in a recent patient-focused article Health Care Quality: Different Meaning For Care vs. Coverage, private payers and government cost cutters simply can’t afford to allow independent physicians to practice better quality medicine than what the government or private payers are willing to pay for because the continued availability of care from independent physicians who put patient needs ahead of payer preferences by their mere existence reveals that payers quality claims are an ugly myth.  To keep this ugly secret, the ACA bypasses the NIH, FDA, HCQIA and peer review and state medical licensure quality assurance processes to set up an entirely new quality system that decides the appropriateness of care for reimbursement reasons with cost containment as a primary motivator while the Obama Administration health care fraud squad and private payers use a variety of tactics deter or punish physicians from offering or providing and patients from seeking or receiving care outside the control of these payers.  Some of these tactics that all physicians know well include:

  • Creating PQRS and other payer centric credentialing or “transparency” rankings which misalign physicians that elect not to participate or that choose to put patients before payment by engaging  in medically acceptable, but payer disapproved practices Refusing to cover and pay benefits to patients or providers for out-of-network claims by characterizing the claims as excluded from coverage as medically unnecessary, overprescribing, experimental or otherwise inappropriate.  While some patients might be able to absorb some of these costs, the harsh reality is that most patients – and particularly those that suffer from chronic or serious medical conditions where physician independent is most critical – can’t afford to absorb these costs for long and are forced to comply to secure the coverage necessary to keep their care affordable.
  • Increasingly aggressive, payer promoted if not initiated “consultation” with patients considering using out of network providers or disapproved treatment plans where provider paid “patient advisors” work to convince patients that their initial choice is not the best choice and to instead use the providers and treatments preferred by the payer rather than those recommended by the out of network provider.
  • Pressuring ACOs and other institutional health care providers not to grant privileges or otherwise work with physicians that are out of network or who otherwise don’t take orders from the payers.
  • Even when patients are willing to pay for out of network care, attacking  the independent physician by targeting, and encouraging medical staffs, medical societies, licensing boards and other quality organizations to target  out of network or other physicians that don’t follow payer driven guidelines for medical board, OIG, peer review, or other fraud or quality investigations, regardless of whether the care is provided in or out of network.
  • Continue to spread the myth that patients can’t trust physicians without oversight from government or insurance “watchdogs” by using the above strategies, physician efforts to lobby for better reimbursement and other payment issues, and other tactics to demonize physicians as motivated by greed rather than patient care.

I trust quality physicians, not the government or insurers,   to help my family and friends decide how to deal with our medical condition and other health decisions. Patients and their families need to clearly understand what the best medical option without regard to cost is, and then openly discuss the tradeoffs and potential risks of compromise due to cost.  I think  members of Congress and all American families want this too, as long as it is made clear to them that this is really what the fight is about. Accordingly, without taking away from the importance of working for progress on the direct question of reimbursement, I urge all to include and lead with the quality discussion.  Failing to protect and defend the control of physicians to define quality of care is the foundation upon which all of the rest of your efforts depend.

The discussions here are inspirational and powerful. I urge all to continue to share these discussions internally and externally with the physician community, as physicians across the country share your frustration and I am confident are hungry to join your cause.  Along with recruiting physician support, however, keep in mind that your most powerful ally in this battle to preserve quality in American health care are the Americans who are your past, current and future patients and their families. but primarily written from the physician’s perspective of how it impacts the physician.  Since the success of your efforts depends on the ability to recruit and motivate patients and their families to speak up and support your efforts, however, I also encourage all to continue to recast, express and distribute as widely as possible these issues from the perspective of the harm these practices are inflicting on patients and their families.

Whether it feels like it or not, you are making a difference!

Thanks for letting me participate in your efforts.  Let me know how I can help.

Cynthia Marcotte Stamer, Esq.
Board Certified – Labor & Employment Law by Texas Board of Legal Specialization
Cynthia Marcotte Stamer, PC

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