The Latest Medicare Ploy
Paul S. Koch, M.D.

The latest ploy by Medicare to micromanage the practice of medicine is this new program they are calling Pay-For-Performance. Sounds great, doesn't it? Finally, it seems, a break from the silly pay tables we have now, which pay everyone the same, regardless of experience, skill or outcomes. Physicians could be compensated like other professionals, on a scale that pays those on the top more than those on the bottom. Can this be true?

Of course not! This is shaping up to be no more than a foolish flapdoodle, designed to sound a whole lot better than it is. Most likely, we will spend more to qualify for the bonus than we will ever receive. Initial rumors insist that to be considered a "good" doctor one must have electronic medical records (EMR). Why? To make it easier for them to review us strikes me as the obvious answer.

Initial rumors have the bonus for performance at +2% and the penalty for nonperformance at –2%. If you take in a cool half-mil from Medicare, that bonus would get you 10 large, leaving you with about $5,000 after you pay the taxman. For that you're going to invest in an EMR system and change office protocols?

Our Academy was asked to suggest some clinical measures that could be used to judge us. The last ones on their list were logical: ask about visual function before cataract surgery and make sketches of cupping in glaucoma patients.

Guess what was number one — the single most important thing an eye doctor should do to be considered excellent? Give up? Here it is. "Counseling on the importance of blood sugar and monitoring of HgA1c in patients with diabetes mellitus."

According to our Academy, more important than vision analysis, excellent eye surgery, or making astute eye diagnoses, is talking to patients about HgA1c levels. Isn't that the job of the endocrinologists and diabetic educators, the people who handle systemic diabetes? I'm sympathetic to their problem of patient compliance and I'm happy to lend a hand, but that doesn't make it a higher priority for eye doctors than taking care of eyes.

Back to the Drawing Board

Happily, CMS decided not to implement the Academy's suggestions, so it's back to the drawing board. A task force is being pulled together from the specialty societies to draft a new set of relevant guidelines. Maybe this group will come up with suggestions that better reflect the trenches rather than the towers.