This May, after I had given a presentation on primary care at a health care summit in the Statehouse, an audience member asked me what I was doing to address “social determinants of health,” as if homelessness, poor nutrition and drug addiction in general were my responsibility. Not wanting to reveal being irked by the question putting this burden on me personally, in addition to all the other problems with performing primary care, I said something about giving patients more time and I did my best.
Later on, I realized that I should have mentioned the importance I place on knowing my patients, especially if they have a limited ability to pay for medications or other limited resources, such as a lack of family members to help care for them or provide transportation. In fact, the first minutes of meeting with a patient making small talk, I’m quickly probing for this information and the patient’s general status.
What I wasn’t expecting was that after that summit, assessing social determinants of health – or SDOH – became the newest “value-based care” data for primary care doctors to gather and document. In reality, what this means is my medical assistant has to spend another two minutes going over a questionnaire with all patients and if there are areas of concern, they get a paper printout with a list of resources. Voila! Another achievement for “value-based care.”
I can’t say that the extra effort was 100% a waste of time. But in comparison to having a caring, interested, unhassled physician, it was. Furthermore, the extensive SDOH documentation in the chart made it hard to find other information. All other specialties have refused to do “value-based care,” and somehow primary care has gotten stuck with it, again.
This example is just the latest intrusion of “value-based care.” Almost every month for the past five to 10 years, we have had a new task added on. The electronic medical record computer programs weren’t designed for collecting this data, so we usually use clumsy workarounds, generating useless paragraphs of text that clog up my notes.
The mantra of needing data to fix health care is not working well, and in some instances, may even be harming the patients. For example, by putting undue pressure on physicians to keep patients’ blood pressures down by grading physicians on this data, some patients are being put on too much medication. Blood pressure is often elevated only during the office visit.
Also, because electronic medical records lack interoperability, our office spends extra time tracking down reports on colonoscopies, diabetic eye exams and Papp tests. Sometimes, I wonder if the maniacal emphasis on getting diabetic patients’ A1C’s down and performing colonoscopies strains my relationship with patients and creates problems in other areas. Am I more concerned about making my numbers look good or am I looking out for their best interest? An elderly patient with slightly elevated A1C is less of a concern than the same results for a younger patient.
Digging into “value-based care,” many of these goals originate from a nonprofit called the National Committee for Quality Assurance, formed in 1991 by respiratory therapist Margaret O’Kane, who still runs the organization. She made more than $1 million in 2023, according to the nonprofit’s tax filings. Eight others at the organization made over $400,000. The nonprofit has $117 million in net assets and took in $98 million in 2023 alone. It brought in $44 million in 2023 from mandatory “accreditation” services and $21 million from “information products.”
Although the endpoints have merit, the health insurance companies use them to promote their companies, the insurers have dumped the burden of pursuing them on an already hollowed out, stressed primary care community.
Additionally, while the National Committee for Quality Assurance seems to think health care can be simplified to numbers, it is losing sight that at its core, caring for patients requires a physician who feels respected and who is motivated to do his or her best for the patient. The recent overemphasis on generating data and determining payment by data has practically obliterated the most important thing I say during my appointments: “Hi, how are you today? Do you have any concerns about your health?”
Dr. Howard Schulman has been a general internist in Rhode Island since 1995.
