Two decades ago in family practice residency, I had the first of recurrent experiences with different patients during my time there – and I’ll bet the farm the same thing happened to you. Middle-aged patient comes in with multiple medical problems, some of which are known or some unknown to him (or her, or now (insert your pronoun of choice)). You diligently work up every damn little thing, counsel him against smoking, write out his problem list and medications, remind him not to smoke, go to the sample closet (those reps left us such great lunches, how I miss ’em), come back with an otherwise very expensive bag of meds, put in patient’s hand, go over the written instructions and why each pill is important, remind him again not to smoke, and walk him to the lobby to schedule a follow up in 2 weeks. Said superstar returns having only taken the meds occasionally “when I feel bad”, or not at all, with no objective, measurable improvement in any vital sign, lab, chest x-ray, or physical finding. And he is, of course, still smoking. Thus was residency.
While the percentage of such patients might vary with geography and demographics, there will always be such in every primary care environment. And now the good ‘ol AAFP has published a way to deal with these patients through a nifty tool called the Self-Management Support (SMS) score.
20 “providers” in an ACO were interviewed, and divided into the top ten and bottom ten of who achieved the best “patient activation.” “Patient activation was defined as having the knowledge, skills, confidence and motivation to manage one’s health and health care.”
Those healers deemed to be the best performers all used the following 5 strategies: lifestyle behavior change, emphasizing patient ownership, partnering with patients, identifying small steps toward change, scheduling frequent follow-ups, and showing care and concern.
“Using psychometric testing”, researchers then used a 9-question scale to give each clinician a SMS score. Lower scores indicated less engaged providers, and higher indicated more engaged. Researchers stated that female providers had significantly higher SMS scores than the men. And I could speculate all damn day on the reasons for that disparity (and I would love to read your take!).
Researchers then applied SMS scores to patient charts to discover “significant but modest associations with their patients’ smoking cessation and weight loss (among obese patients).”
These academic pointy-heads also want to “investigate what other members of the health care team could do to support patient self-management”, given that the provider will now have even more useless crap to measure without any more time. And of course someone has to pay those other “team members.”
Do you see where all of this is heading? Providers will increasingly be herded and caged into this “quality” farce, which measurements and resultant reimbursements will be based on things like smoking cessation, BMI reduction, HgBA1c reduction, better BP control, etc. Given a link between one’s SMS score and likely patient improvements, a better SMS score – measured by, oh, I don’t know, an ABFM MOC module or a Medicare online questionnaire – will be required for those fleeting bonuses. A lower SMS score might well be used to justify penalties: “A better SMS score would have resulted in better patient compliance, and therefore better quality, ipso facto you cost Medicare/Medicaid/BCBS/Aetna/etc. more money in terms of the potential for increased hospitalizations, complications, and more collaborative co-morbidities, you damn poor excuse for a provider.”
In there ongoing mission to keep us all forever in residency, where its never the patient’s fault, the AAFP, ABFM, AMA, ABIM, et al will gleefully embrace this crap under the banner of “improving the provider-patient relationship.” When SMS becomes prevalent enough, and we all start faking it and studying for the test, it will more likely referred to as “save my shit.”Tweet