How to keep a promise to put patients over paperwork

You may have noticed that your doctor appears tethered to the computer: Less than 15 percent of the average physician’s time is spent in direct contact with patients. It’s no wonder that two-thirds of physicians are burned out.

A Centers for Medicare & Medicaid Services (CMS) initiative spanning presidential administrations, “Patients Over Paperwork,” targets the administrative burdens that are crushing physicians. Overregulation drives these administrative burdens, which ultimately harm patients, push physicians out of small practices into the arms of large corporations and increase costs. This was the subject of a recent House Small Business Subcommittee on Oversight, Investigations and Regulations hearing where one of us was an invited witness.

We both agree that CMS needs to go on a “quality diet.”

Initiated through the work of physician Avedis Donabedian’s health care measurement model — which evaluates structures, processes and outcomes — decades of quality measurement have focused on measuring every minutiae of care delivery. Taking this model as a cue, Congress imposed increasingly stacked measurement models on the health care industry.

Policymakers should rein in the long-loathed “quality industrial complex,” implementing a cap on the number of quality metrics in Medicare and creating a lifecycle for these often-cumbersome measures. A new frame of thinking is desperately needed, as over half a century of attempting to regulate quality has resulted in groupthink.

Many metrics are arbitrary and don’t align with patient-centered, clinically relevant care. More than half lack clinical validity, and some even contradict physician judgments about optimal care. For example, when hospitals were penalized for high readmission rates following heart failure treatment, readmissions dropped while overall mortality increased. The drive for better patient satisfaction scores, which are not reliably gathered, has also been linked to increased costs. The more satisfied patients died at a higher rate, too.

Quality reporting requirements place significant burdens on physician practices and hospitals. An average-sized community hospital employs nearly five full-time staff members solely for reporting quality metrics. Large hospitals can face over 150 unique metrics and spend over 100,000 person-hours annually on reporting. Independent physician practices are also on the hook for reporting their metrics, and the costs are similarly substantial, estimated at $15.4 billion annually. Many independent practices, already squeezed by Medicare’s physician payment cuts, end up selling out to large health systems, driving consolidation and raising costs further.

Also concerning is that quality reporting is expensive for taxpayers. Since 2008, CMS has invested over $1.3 billion in metric development, outsourcing the work to a few contractors — a classic case of regulations benefitting a select few. Unable to prioritize, this bureaucracy has blossomed like an algae bloom with CMS now possessing a staggering inventory of over 2,200 quality metrics.

It’s clear that metric reform is urgently needed, with a 2019 Government Accountability Office report stating the CMS needed to ensure that its quality measurement work actually drove its desired outcomes. As we noted in a recent paper for the Journal of the American Medical Association along with AMA President Jesse Ehrenfeld, policymakers should require CMS to institute a quality-metric lifecycle and cap the number of metrics. CMS should regularly review quality metrics for effectiveness and adverse consequences, with measures sunsetting if there is not definitive proof of benefit or if there is evidence of harm.

Moving forward, most metrics should emerge from the clinical environment, with multiple private groups developing and marketing differing measurement tools. Metrics should utilize artificial intelligence and automation in order to reduce the documentation burden while simultaneously decreasing the likelihood that metrics are gamed by well-resourced institutions. Finally, a new quality domain should focus on improving the clinician experience with an aim to drive competition and drive improvements in clinical operations.

Regulators imposed metrics on physicians and nurses in a well-meaning attempt to incentivize better outcomes. Instead, overregulation of quality has increased costs, harmed patients and driven physician burnout. Ground-up innovation is key to combatting consolidation in the market for the product of quality metrics, with metrics emerging naturally and utilizing automated data collection, thus easing the burden on physicians.

CMS must keep its promise to patients and physicians and put patients over paperwork. Otherwise, instead of having a doctor with a three-star rating, there might not be a doctor at all.

Anthony DiGiorgio, DO, MHA is an assistant professor of neurosurgery at the University of California, San Francisco and a senior affiliated scholar with the Mercatus Center at George Mason University. 

Brian J. Miller, MD, MBA, MPH is a nonresident fellow at the American Enterprise Institute and an assistant professor of medicine at the Johns Hopkins University School of Medicine.

These views are the author’s own and do not necessarily reflect the views of the Medicare Payment Advisory Commission.