- Kenny Lin, MD, MPH
Last night, the U.S. Senate overwhelmingly passed the Medicare Access and CHIP Reauthorization Act of 2015, which, among other things, repealed Medicare's sustainable growth rate (SGR) formula that for the past 12 years had threatened to slash physician payments in order to meet targets for overall program spending. The American Academy of Family Physicians was one of many medical groups that declared victory. Instead of cuts, physicians will now receive annual 0.5% increases to payment schedules through 2019, after which payments will be designed to reward quality over quantity of care.
As many have pointed out, though, the devil of quality measurement is in the details. In family medicine, "high quality" care has often boiled down to how often physicians provide a service to eligible patients: what percentage had smoking cessation counseling, had tests for blood glucose control, or underwent appropriate screenings. Despite the existence of the Choosing Wisely campaign, physicians are rarely, if ever, rewarded financially for forming therapeutic relationships with patients and collaboratively deciding not to provide a service. That's a big problem, since the original intent of the SGR wasn't to improve quality, but to reduce costs (or at least slow the rate of cost growth) of care. Although Medicare officials are hopeful that accountable care organizations will save money in the long run by coordinating care and reducing redundant services, it's not at all certain that this will happen.
Screening mammography is a good example of how current quality measurement approaches could end up increasing costs of care. Fee-for-service Medicare spends about $1 billion each year on mammography; across all payers, about 70% of U.S. women age 40 to 85 years are screened annually at a cost of just under $8 billion. A provision of the Affordable Care Act mandated that women over 40 receive screening mammograms at no cost, and it's easy to measure if women are screened or not. So am I a necessarily a better doctor who deserves higher pay because more of my patients get mammograms? Medicare officials would say yes, but I'd argue that they're wrong. Screening mammography's benefits and harms are closely balanced, and as Drs. Russell Harris and Linda Kinsinger observed in a previous issue of American Family Physician, some women might reasonably make an informed decision to decline this test:
Over the years we have learned more about the limited benefits of screening mammography, and also more about the potential harms, including anxiety over false-positive results and overdiagnosis and overtreatment of disease that would not have caused health problems. More and more, the goal for breast cancer screening is not to maximize the number of women who have mammography, but to help women make informed decisions about screening, even if that means that some women decide not to be screened.
A recent study estimated that patients and insurers in the U.S. spend an additional $4 billion annually on working up false-positive mammogram results or treating women with breast cancer overdiagnoses. That's an extraordinary amount to spend for no health benefit, and it could be substantially less if physicians had the time and resources to explain difficult concepts such as overdiagnosis. But that doesn't appear to be where we're headed.
Don't get me wrong: I'm happy that the SGR is history. There's a lot more work to do, though, to prevent it from being replaced down the line with crude measures of physician quality that will end up costing even more money and make few patients happier or healthier.