This week, the Department of Health and Human Services (HHS) announced an ambitious goal to have 85% of payments made to doctors linked to clinical quality measures within the next two years. HHS believes that incentives should be weighted almost entirely toward quality of care instead of volume of care. I guess if you’re a patient, you could ask yourself the following question: are you currently more frustrated with (1) your quality of healthcare, or (2) your inability to get an appointment in a timely manner?

The truth is that both are equally important. And, since the latter problem will only get worse after eliminating incentives for volume, HHS is essentially betting the future of your healthcare on its own ability to assess and manage quality. Oh, gosh, I just read that sentence again, and nearly collapsed thinking about it.

HHS Secretary, Sylvia Mathews Burwell, in a recent press conference, made the following comment: “As a very large payer in the system, we believe we have a responsibility to lead….” One of my colleagues humorously finished her sentence with the words, “right off the cliff.” But, you should know that this isn’t just a joke. Follow me around for one day and you’ll see how poorly HHS and its Centers for Medicare and Medicaid Services (CMS) are currently leading the charge in healthcare quality.

In fact, Saturday Night Live would have an absolute field day with a parody of the situation. I’d enjoy representing the physician community by playing myself.


CMS: Dr. Bilhartz (Me), have you been participating in our healthcare quality initiatives?

Me: I’m a little confused. Which program are you referring to? I’ve had to sign up for so many that I’m starting to lose track. Are you speaking about the Electronic Prescribing (eRx) program, the Electronic Health Record (EHR) Incentive program, or the Physician Quality and Reporting System (PQRS) program? If you need an account number, just let me know. I’ve got separate ones for Meaningful Use, something abbreviated as ICAS, and another program called Open Payments. I finally hired someone full-time to help me figure it out. I asked her to come today, but she resigned last week citing irreconcilable frustrations having to deal with CMS on my behalf.

CMS: Sounds like you are very knowledgeable about many of our programs. Did you submit your Clinical Quality Measures (CQMs) for last year? This is how we determine how you stack up against other physicians.

Me: Yes, I submitted the ones that were tabulated by my electronic health record (EHR), the same EHR that you allowed me to use because it was “certified.” Just for the record, these EHR systems have more bugs than my windshield during insect mating season. But, I’m still trying to use it and follow all those meaningful rules that you created along with it.

CMS: We know that you are a heart doctor. Did you submit a specific CQM that deals with cholesterol management of your patients?

Me: Yes, that one was interesting. The quality metric was based on a guideline statement that was published in 2004. I’m not certain if you know this, but we actually update guidelines in medicine from time to time. In fact, we don’t really focus on a specific cholesterol number anymore. We prefer to assess patient risk factors.

CMS: What are patient risk factors?

Me: Oh, sorry, I forgot that most of your physician administrators don’t see full clinic schedules of patients anymore. Just know that I did as you requested and submitted my quality numbers, even though your cholesterol metric was outdated.

CMS: How did you do?

Me: Not too well. My EHR tabulated that I saw 1527 patients over a 90-day time period last year with significant heart and vascular disease. I know this number isn’t accurate. It’s what my certified EHR spit out, but it’s not right. I see a lot of patients, but I didn’t see over 1500 unique people in 3 months with heart and vascular disease. I guess it counted people twice. I’m not certain. I didn’t program the software, but the worst part is that it tells me I only helped 44 of them. I’m not sure how it arrived at this number either. Like I said, the whole thing is a disaster.

CMS: Don’t worry about that. The lower your numbers, the more money that we get to keep. Just keep sending us whatever your EHR gives you. We are using that information to develop all kinds of conclusions about the quality of care that you are providing. Then, we will use this information in the future to teach you how to improve. You won’t even need to read new medical research in order to keep up-to-date with your education. Our robust quality assessment programs will do this for you.

Me: But, doesn’t poor information inserted into the equation always result in worthless conclusions coming out of it? Besides, your entire system accentuates one major problem in medicine right now: the over-reliance on data. For example, you can’t measure quality in medicine the same way that you calculate batting averages in baseball. Medicine is still just as much of an art form as it is a science.

CMS: We believe that collecting more data is the only way to establish an integrated healthcare system to care for our Medicare and Medicaid patients.

Me: I know all about integrated healthcare systems. In fact, I once worked within a government-funded one. And, respectfully, I’m not convinced the Veterans Health Administration (V.A.) is our model of excellence.

CMS: Data. Data. Data.

Me: You sound like a robot, more focused on documenting healthcare than adding value to it. You are completely forgetting what has made America so great: our capitalism. Less tanker ships. More agile tugboats with vested-interest competing with each other driving quality. If you give everyone a health savings account in a system with more physician-ownership and transparent medical pricing, the market will drive quality better than CMS every day of the week and twice on Sunday.

CMS: I think I just need more data to understand it all. Can you write it down for me?

Me: I did. Read my book.