New Job, Old Nemesis: The Quality Bonus

Kenneth W. Lin, MD, MPH


July 27, 2022

Hi, everyone. I'm Dr Kenny Lin. I am a family physician at the Lancaster General Hospital Family Medicine Residency, and I blog at Common Sense Family Doctor.

After moving to a new city, before seeing my first patient, I spent quite a few hours becoming oriented to the logistics of my new practice. Tasks included setting up my username and password, learning how to compose notes and enter orders in the electronic medical record, meeting with the billing and coding team, and understanding the bonus structure for meeting certain quality metrics.

In my previous practice, one half of the quality bonus was based on my patients being up-to-date or well controlled on breast and colorectal cancer screening, depression screening, and hypertension and diabetes management. One quarter was based on the "population health" metric of a certain percentage of eligible patients undergoing Medicare annual wellness visits. The remaining quarter was based on a "patient experience" metric, in which patients were asked about the likelihood of recommending their primary care doctor to others.

In the past, I usually did not qualify for the quality bonus. I received high patient experience ratings, but enough of my Medicare patients weren't aware of or interested in having a wellness visit, and I struggled to show that patients with white coat hypertension who had high blood pressure readings recorded in the office were under good control at home, where it matters. Further, because I sometimes could not obtain the reports of mammograms and colonoscopies patients had at locations outside of our health system, the percentage marked as "up to date" on these screening metrics remained artificially low.

My new practice uses a similar set of metrics that, if achieved, also result in an annual quality bonus. In addition to the adult metrics, they have focused on childhood lead screening. After learning that some parents were not bringing their children to the laboratory, they encouraged nurses to instead do a capillary draw at the office visit. This helped, but it wasn't a perfect solution because nurses are often too busy rooming other patients, giving vaccinations, or returning phone calls to remember to collect this blood sample before the patient leaves. So I suspect that my odds of earning a quality bonus in my new practice may be long.

In theory, it's not a bad idea to provide financial incentives for doctors to keep their patients satisfied and provide preventive care and treatment that is consistent with best practice standards. But, I have problems with the way quality measurement is typically practiced. First, the metrics are not always evidence-based. For example, the US Preventive Service Task Force found insufficient evidence that testing lead levels in asymptomatic children improves health outcomes. Second, a family physician often has limited influence over whether a metric is met. Getting patients to schedule preventive care and screening tests, receive recommended vaccines, and pick up and take prescribed medications requires practice level or health system level interventions, such as automatically generated letters, phone and text reminders, and public awareness campaigns.

In a recent commentary, Drs Christine Sinsky and Jeffrey Panzer distinguished "solution shop" from "production line" work in primary care and argued that though the medical training physicians receive makes us uniquely qualified to do the former, we end up spending most of our time and energy on the latter. Similarly, they observed that "most quality-improvement efforts have focused on improving production line–type measures and not on improving the conditions for sound medical decision-making and relationship building." Being able to correctly diagnose and treat patients who come in for chest or abdominal pain, for example, counts less (or not at all) toward my quality score compared with the percentage of patients who receive lead screening or diabetic eye exams.

Several years ago, Dr Michael LeFevre, a family physician colleague, criticized the quality measurement industry for its near-exclusive focus on "measuring healthcare processes and intermediate outcomes, not health". Aside from patient satisfaction, he noted that none of the metrics that were then used by Medicare's Merit-based Incentive Payment System assessed achievement of the pillars of primary care: first-contact care, continuity, comprehensiveness, and coordination of care. Although the Centers for Medicare & Medicaid Services has since recognized several metrics developed specifically for this purpose, "production line" metrics still dominate the field.

I hope that sometime in the future, quality metrics will be better aligned with health outcomes and patient autonomy (a well-informed woman may decline to have breast cancer screening owing to the potential harms, for example). In the meantime, as the new family doctor on the block, I will focus on developing strong relationships and building trust with my patients and addressing what matters most to them, regardless of the impact on my quality score.

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