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Unhappy Camper Vol. 1, Issue 8

I was a physicians’ group meeting this past week where I was handed yet another set of P4P Quality Measures derived from the NCQA . We were all expected to comply with this set of standards over the upcoming years.  One of these measures stood out from all others as being problematic in my mind, entitled: Appropriate Treatment for Children with Upper Respiratory Infection: (The percentage of children in the denominator who are not prescribed an antibiotic for an upper respiratory infection).  It is certainly a good thing to withhold antibiotics unless the patient needs one for a bacterial disease.  Microbial resistance is a big problem and, yes, we all have to do a better job in avoiding the inappropriate usage of antibiotics.
 
The problem is that the denominator criteria requires that we assess children with the diagnosis of URI ONLY using ONLY the ICD9 codes of 460 (common cold) or 465 (URI, unspecified site).  The criteria specifically excludes any patient that has any other or additional diagnostic codes appended. One might believe that this was done so patients who had other problems, such as an ear infection, could be treated with an antibiotic while being excluded from the data set and not penalize the physician’s performance data.  But there’s another problem here.  The requirements lead us to deliberately not document other diagnoses that we need to be capturing for true quality medical care.  It invites physicians to dumb down the data solely for the reason of chasing P4P data success. More enlightening discussion on P4P and ‘physicians gaming the system’ can be found in the RAND COMPARE study, Analysis of Physician Pay for Performance (2010) at: http://www.randcompare.org/analysis-of-options/analysis-of-physician-pay... , and in Michael Cannon’s paper on this subject in the Yale Journal of Health Policy, Law, and Ethics VII:1 (2007), at: http://www.cato.org/pubs/papers/cannon_p4p.pdf .

I like to think that I’ve trained my parents and patients well and, indeed, most of my older-than-toddler pediatric patients do not come in for an office visit for simple URIs that can be best served with standard home treatment measures.  Patients usually come into the office with complaints much more complex than a simple cold. So, in order to chase those P4P dollars, I can do one of two things.  I can either ‘stack the deck’ by bringing in (and billing) for office visits all those patients best served by home treatment, or I can falsely eliminate legitimate diagnoses from the encounter, leaving only the cold diagnosis to be submitted. In the first case, I’d be charging the P4P insurance payor office visit fees that could have been avoided.  In the latter case, I’d be charging less than fair value for the work I performed when taking care of all those other items that needed to be addressed during the visit. Is this a wise business practice from either the payor or provider? Probably not.  Is this good for patient care?  NO! 

One local physician group has been telling their docs to deliberately NOT add other diagnosis codes onto the URI code specifically so they can qualify for this P4P measure. If all physicians are deliberately trying to diagnose ONLY a cold/URI in order to document P4P measures compliance, we fail to document what’s really out there.  Influenza, croup, pertussis, and a host of other important URI-associated diagnoses all become incentivized into being lumped into the 460/465 common cold/URI diagnosis.  Public health monitoring of certain diseases like these may be adversely affected.  But also, physicians will possibly end up increasing their own liability by not documenting that they at least considered alternative diagnoses than just the common cold.  I have written in previous columns about how EMR can lead to a dumbing down via minimalist documentation (see http://www.docehrtalk.org/messageboard/2010/08/13/unhappy-camper-vol-1-i... ), and this is yet another form of it.  I truly believe that this money chase mentality will, in some instances at least, diminish the true quality of medical care, all led by the bureaucracies that dangle these carrots in front of our noses.