Are More Doctors Cherry-Picking and Lemon-Dropping Patients?

Leigh Page

Disclosures

February 15, 2017

In This Article

Will New Payment Programs Encourage Cherry-Picking?

When physicians worry about being forced to select patients, they're often thinking of the future.

Those commenting on cherry-picking in the Medscape poll used a lot of "ifs." A family physician said the pressure for him to cherry-pick "depends on if I was getting paid fairly for each patient." And an HIV/AIDS doctor stated, "If my ratings and livelihood depended on outcomes, I would probably cherry-pick patients to some extent."

The much-anticipated value-based payment system is still very much a thing of the future. Many physicians are in accountable care organizations in the Medicare Shared Savings Program (MSSP), which pays physicians for their outcomes, but only 30% of accountable care organizations earned shared savings in 2015, the latest reported year, according to a September analysis[7] in Health Affairs.

Meanwhile, Medicare is launching several new mandatory bundled payment programs in which payments for hospitals and doctors will be based on patient outcomes. The first and only one so far, the Comprehensive Care for Joint Replacement (CJR) for orthopedic surgeons and hospitals, just started in April, so it's too early to tell how much cherry-picking will ensue.

"Bundles represent a huge risk," says Alexandra E. Page, MD, an orthopedic surgeon in San Diego who chairs the Health Care Systems Committee of the American Academy of Orthopaedic Surgeons. She noted that in an earlier orthopedic bundling program, some practices took out reinsurance to cover their financial risk.

Dr Page says that the CJR lacks a good risk-stratification system, putting orthopedic surgeons at risk for big losses if they have a lot of high-acuity patients. She argues that CJR should have been made voluntary while the bugs were being worked out.

One long-standing incentive to cherry-pick patients is report cards issued by health systems, payers, and state regulators, which rate physicians on their outcomes or their ability to meet various process-of-care measures. Sometimes the scores help determine payments, but usually they're simply posted on public sites.

A 2003 study[8] found that in New York and Pennsylvania, two states that collected and reported surgeons' results for coronary bypass operations, heart surgeons engaged in a significant amount of cherry-picking.

Meanwhile, under Medicare's Physician Quality Reporting System (PQRS), physicians have been reporting metrics on meeting certain process-of-care measures. PQRS is being folded into Medicare's new Merit-based Incentive Payment System (MIPS), which started in January.

Many people fear that MIPS will prompt physicians to cherry-pick. PQRS scores have begun to be posted on the Physician Compare website, and MIPS scores will be posted there as well.

Should Cherry-Picking Be the Norm?

An internist in the Medscape survey was concerned about these postings. "How many physicians would choose to take care of more complex patients, get penalized for it, and then have their name placed on a public Internet site as a bad physician?" he asked. "The question is not, would you cherry-pick? The question is, why would you not cherry-pick?"

David Zetter, a practice management consultant in Mechanicsburg, Pennsylvania, basically agrees with this assessment. "What government has just done with MIPS is going to create all kinds of cherry-picking," he says. "Physicians will be assessed under the quality performance category [formerly PQRS], and their scores will be posted on the Physician Compare website."

He added that low-scoring physicians might not be able to get into a payer network, which would be another reason to cherry-pick.

However, the full impact of MSSP, CJR, MIPS, and Physician Compare has yet to be felt, so it's not clear how much cherry-picking they would stir up.

Screening Patients Ahead of Time Isn't So Easy

It's often said that the best time to evaluate or select patients is during the initial visit, before the patient has been accepted by the practice. Once the patient is accepted, you would then have to start a process to sever relations with the patient.

Unfortunately, the initial visit is the time when you least know your patients, so you'd have to take extra steps to research them to see whether they have too many chronic conditions or whether they were nonadherent with past doctors.

"I think it would be hard to do this in an office setting, because you will not know the patient's medical history until they come in," a family physician told the Medscape survey.

MedPro Group, a malpractice carrier, advises[9] doctors to ask patients to supply their medical records in advance and use the initial visit to look for potential problems. "Initial consultations with new patients present practitioners with a unique opportunity to identify potential signs of noncompliant or difficult behavior," the company advises.

Borglum suggests having a "get to know you" visit with the patient. The visit "gives the doctor a chance to see whether the patient is obese, infirm, or has other obvious exclusionary health problems, allowing you to weed out difficult patients," he says. "But you can't diagnose, prescribe, or treat, because then they would become your patients."

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