If you are part of a patient-centered medical home (PCMH) then you know there are a lot of boxes to click, metrics to measure, and bundles to burden your practice. This is data driven healthcare, which evolved from a holistic approach first introduced by the American Academy of Pediatrics in 1967. It was meant to coordinate care in a family centered approach.
Fast forward to 2006 when the Patient Care Collaborative (PCC) was founded by a large number of “stakeholders,” including employers such as IBM, large insurers, and major healthcare systems as a way to drive quality improvement into the practice of primary care. But what good is a metric if you don’t have an accrediting body to determine whether your care is adequate? Once metrics were identified, the National Committee for Quality Assurance (NCQA) and the Accreditation Association for Ambulatory Health Care launched recognition and accreditation programs. NCQA is a private 501c not-for-profit organization that states it is “dedicated to improving health care quality.” A quick look at its “Platinum, Gold, and Bronze” sponsors reveals a who’s who of the pharmaceutical industry, while its lower level sponsors are a long list of predominantly insurers. NCQA gathers data on large healthcare systems who pay them for PCMH recognition, and then in turn sells that data through their Quality Compass product to insurance plans, states, big pharma, and consultants. Additionally, the NCQA collects data at the federal level on behalf of CMS for Medicare programs, which they then sell to the Medicare market.
Which metrics are important to the PCMH accrediting body? And do these metrics translate into better health for our patients? In the decade and a half that the PCMH has been in force, the morbidity for non-communicable disease in the U.S. has increased over 10%. These are the usual diabetes, hypertension, dyslipidemia, and cardiovascular diseases that are so closely linked to lifestyle, diet, exercise, and socioeconomic status. Reported patient metrics include measures of control such as HbA1c, LDL cholesterol, blood pressure, and urine micro albumin. They are reported though electronic health records that cost millions upon millions of dollars, with updates every few months to create new best practice advisories (BPAs) so that doctors and providers can be reminded that there is a box to click. The BPA reminds me to ask Mrs. Jones — who is being seen for her opiate addiction, bipolar disorder, and recent death of her mother — if she might possibly be feeling hopeless several times this week.
The clear irony here is that whether it is documenting the trite PHQ-9 questions to people with profound psychosocial angst, or getting yet another HbA1c on a 300-pound patient who can’t afford a dietitian, we have no resources to get these patients the help they so desperately need.
While vast sums of money are being thrown at all these layers of bureaucracy for data mining, patients are suffering in ways and numbers that are exponentially higher than just two decades ago. Basic medications such as insulin, albuterol, and blood thinners are exorbitantly expensive. We have no social worker at our hospital, no counselors in our clinic. Patients may gain 40 pounds and be depressed, but if their metrics are to target then your scores are good and your organization gains accreditation or recognition and reimbursement goes up.
Now, we are on the verge of yet another concerning paradigm shift in the data mining frenzy that is PCMH. On March 29, 2022 the PCC put out a YouTube video to kick off their campaign (read raising money) that will fund the lobbying of Congress and the Executive Branch in the retooling of how you practice medicine. No longer focused on fee-for-service, the PCC site links to the National Academies of Sciences, Engineering, and Medicine publication, “Rebuilding the Foundation of Health Care.” This change in modeling seeks to implement a Hybrid Model of reimbursement that is part fee-for-service and part capitation. When questioned about the “asks” that will be placed on physicians, providers, and nurses, the CEO of the Primary Care Collaborative Ann Greiner, MCP, stated that they “did not have an answer…about what will be required of primary care physicians,” but that members of their organization would “not agree to burden clinicians unnecessarily.” Given that this is the group that gave us the metrics-driven healthcare that has caused millions of Americans to become numerators or denominators in the Healthcare Effectiveness Data and Information Set (HEDIS) system formulated by the NCQA, one would fine this of little consolation.
One of the primary sponsors of the PCC is The Commonwealth Fund. This organization is currently sponsoring a Commission to put forth the agenda of a national public health system, citing the lack of a coordinated response to the COVID-19 pandemic. Their stated goal is as follows:
“This report is intended to inform the transition to a national public health system through more directed use of grant and other federal funds, the resetting of roles and expectations, and reform of legal authority.”
Metrics are increasingly stumbling blocks to the clinical judgement that used to be the bedrock of the patient-physician relationship. Just recently I was queried on my not meeting the metric of a statin for a patient with diabetes. My prior note detailed that this woman with dermatomyositis had an HbA1c of just over 6, and was currently having significant symptoms of myalgia, which could be exacerbated by the addition of a statin. The devil is in the details, and patients are full of details. In a recent article in the New England Journal of Medicine entitled “Metric Myopia — Trading Away our Clinical Judgement,” David Blumenthal, MD, MPP, is quoted as writing in 1997 that such variations of care have, “emboldened purchasers and policy makers to challenge physicians’ claims that they know authoritatively what constitutes optimal health care.” Ironically, Blumenthal is now president of The Commonwealth Fund.
When we realize that these are the sponsors and stakeholders who are funding the data collection that will change primary care over the next decade, we must stop and wonder, where is the patient in all of this? What good is taking “Standardized Social Determinants of Health” surveys in patients who can’t afford to get their most basic needs met? A survey of a patient in a half-way house, batting meth addiction does nothing to get him a psychiatrist. It does, however, inform the accrediting body to further adjust the potential reimbursement for a medical system showing a patient base that is socioeconomically disadvantaged. Why is this important to the big players in healthcare? As we move toward a national health system that reimburses based on metrics, there is a fixed amount of dollar resources, which results in a zero-sum game. Resources will be determined by use of the data that is mined within the walls of the exam room.
As physicians, we need to stand up to the layers upon layers of special interests who have taken over the primary care of our patients. The whole point of surviving 4 years of medical school, years of sleepless work in residency, and taking exam after exam is that we should have the ability to know what is best for each individual patient in that moment as we sit with them. We are not automatons to administer surveys. These patients are not HEDIS data sets. They are our friends, neighbors, and colleagues. We should be defending them and the art of medicine against the mechanistic autocracy of pharmaceutical and insurance stakeholders lurking behind the slick proposals for “resetting” primary care.
Kathleen A. Hallinan, MD, MPH, is an internal medicine specialist in Corning, New York, and a diplomate of the American Board of Obesity Medicine.