I strongly oppose use of quality measures that incentivize or penalize physicians based on their ability to influence patient actions when those actions are beyond reasonable control of physicians or if there is no evidence linking such actions to improvements in patient outcomes. That is why I believe there is a dangerous precedent being set in the Stage 2 electronic health record (EHR) incentive payment rule which will penalize physicians if they fail to influence patient behavior in a manner desired by the Centers for Medicare & Medicaid Services (CMS).
Two of the 17 Stage 2 core objectives hold physicians accountable for ensuring that their patients use technology at home. One measure requires at least 5% of unique patients seen during the reporting period to send a secure message to the physician's practice using the electronic messaging function of the EHR. A second measure requires at least 5% of unique patients seen during the reporting period electronically view, download or transmit their health information.
In order to qualify for Medicare and/or Medicaid EHR incentive payments and avoid financial penalties, physicians must meet all 17 core measures as well as three from a menu of six additional measures. Physicians must also report on nine of a total of 64 specific clinical quality measures. Physicians who fail to do so by 2015 will not only fail to receive annual EHR incentive payments, but also be penalized by CMS through annual payment adjustments.
In the final rule for the Stage 2 EHR Incentive Program CMS responded to public comments on these two new core objectives. CMS argued that physicians are in a unique position to strongly influence the use of technologies by patients "to improve their own care." They did acknowledge a potential barrier of limited broadband internet access that could impact some physician practices and patients. So in the final rule CMS lowered the threshold from 10% to 5% and added an exclusion for practices that are impacted by limited broadband access. CMS summarized their response with, "We believe that this lower threshold, combined with the broadband exclusion detailed in the response, will allow all EPs (eligible physicians) to meet the measure of this objective."
I can agree with CMS that physicians should leverage the influence we have on patient behaviors as part of the care we provide. We certainly are in a unique position to help patients become more engaged in and compliant with their healthcare. I even agree with CMS that the lower thresholds should not be difficult to meet and that it is important for physicians to offer these technologies for patients to use.
My key point of contention with CMS is with the presumption that use of these specific technologies at home allows patients to "improve their own care". If use of these technologies were objectively linked to improved patient outcomes, I could understand the value in financially incentivizing physicians to move patients in that direction. Without such evidence the government's relationship with physicians would be better served through a more tactful approach to promote the use of promising technologies by patients without the strong-armed threat of financial penalties on doctors.
CMS misses the point on this one. Precedent should not be set to penalize physicians based on measures of their ability to engineer desired patient behaviors when those behaviors are not objectively linked to improved patient outcomes. I am not saying that we should not offer these technologies to our patients. I am saying that we should promote their use and then study how that use impacts the quality of care