Key points

Introduction

As US policymakers continue to grapple with unacceptable rates of medical errors, unsubstantiated variations in practice patterns, and potentially avoidable spending, physicians are finding themselves in the center of a perfect storm. Today’s physician faces not only multiple, often conflicting, regulatory requirements that interfere with the daily practice of medicine but also an unprecedented level of accountability for factors often outside their control and of questionable significance. These misguided mandates, aimed at improving US health care system performance, have produced little evidence to date of actually raising the bar on anything but confusion and frustration.

Despite significant financial investments, the United States remains one of the least efficient health care delivery systems in the developed world. US physicians also have one of the lowest rates of job satisfaction. Frustrations are likely to increase as patient-centered care is further eroded, and physicians are forced to divert an increasing portion of their attention to administrative compliance with one-size-fits-all care mandates.

Although many reforms are being implemented in the private sector and at the local and state level, most are driven by policies enacted at the federal level. Recent federal regulatory actions have shepherded in a new era of health care delivery and payment reforms that has fundamentally restructured incentives and revolutionized information sources that drive clinical decision making. These reforms were heavily influenced by the findings of the Institute of Medicine, which not only identified dramatic deficiencies in the quality of US health care, but demanded that the nation aggressively address these problems.

As early as 2006, President Bush issued an executive order “to ensure that health care programs administered or sponsored by the Federal Government promote quality and efficient delivery of health care through the use of health information technology, transparency regarding health care quality and price, and better incentives for program beneficiaries, enrollees, and providers.” The Tax Relief and Health Care Act of 2006 was enacted soon after, establishing the Physician Quality Reporting Initiative (now known as the Physician Quality Reporting System or PQRS). The Medicare Improvements for Patients and Providers Act of 2008 made the PQRS a permanent feature of the Medicare program and authorized financial incentives and penalties for electronic prescribing. The groundbreaking American Reinvestment and Recovery Act of 2009, which included the Health Information Technology for Economic and Clinical Health (HITECH) Act, subsequently authorized a more than $19 billion investment in the nation’s health information technology (HIT) infrastructure and federal incentives to encourage physicians and hospitals to use HIT in a meaningful manner. The Patient Protection and Affordable Care Act (ACA) of 2010 went one step further by transforming these largely voluntary, incentive-only initiatives into mandates with increasing penalties. The ACA also heavily emphasized value over volume, holding health care providers accountable for not only the quality of their care, but their ability to control costs.