|Current literature is replete with discussions of implicit and explicit
discrimination against patients and, as of late, with studies regarding
the benefits and drawbacks of the Physician Quality Reporting System
(PQRS). This article investigates an area of overlap between these
two topics that deserves more attention in the public discourse. The
article sheds light on the current PQRS quality metrics with regard to
HbA1c, blood pressure and LDL measurements and suggests that they
encourage discrimination based on weight. The article outlines the
clinical and moral drawbacks of the quality metrics as they stand and
suggests that the current wording be reconsidered.
|In this critical historical period in American medicine in which few
assumptions about healthcare seem to go unchallenged, many providers
and patients still cling to a basic premise that they hope will remain
unscathed: healthcare is a fundamentally humanitarian profession and
its providers are caregivers for society as a whole.
|Although this assumption enjoys relative immunity in the literature,
the field has seen considerable shifts that fundamentally undermine it
in practice. In a recent article in the New England Journal of Medicine
titled, “Discrimination at the Doctor‘s Office,” Holly Fernandez Lynch
responded to a growing trend by which physicians deny care to patients
on “questionable grounds, including the patient‘s sexual orientation,
parents‘ unwillingness to vaccinate… and most recently, the patient‘s
weight” . Lynch argues appropriately that such practices are legally
prohibited and should not be deemed acceptable within medicine.
She argues further that “we should condemn all types of invidious
discrimination,” and that “we should be particularly vigilant” against its
subtle forms. While true, these words of advice don‘t begin to address
the problem. Discrimination surfaces when societal and institutional
norms allow it and when the healthcare system is designed to encourage
|Of particular interest to the medical ethics community is the
discrimination against patients based on their weight. The potential for
a physician to act in a biased manner towards patients based on their
individual weight exist both implicitly and explicitly within medical
practice. Sabin et al.  demonstrate the strong implicit and
explicit “anti-fat” bias expressed by physicians based on a statistical
analysis of the Project Implicit® Weight Implicit Association Test (IAT).
Physicians‘ performance on the Weight IAT demonstrated a strong
implicit anti-fat bias on par with the general public. A similarly evident
explicit bias was indicated in their self-reported preference for people
who are thin versus overweight or obese .
|Unfortunately, this problem is deepened considerably by the recent
implementation of the Physician Quality Reporting System (PQRS) .
|The very first measure listed in the 2013 PQRS Measures List
is titled, “Diabetes Mellitus: Hemoglobin A1c Poor Control.” The
accompanying description reads as follows: “Percentage of patients
aged 18 through 75 years with diabetes mellitus who had most recent
hemoglobin A1c greater than 9.0%” . Similar phrasing is used for
measures regarding controlled low-density lipoprotein as well as
hypertension. Although most measures in the 2013 Measures List focus
on physician interventions (such as administration of aspirin to patients
with CAD), the ones previously mentioned focus on the health statuses
of their patients. The significant impact of this particular system is that
physicians‘ bonuses and deductions are not based on their efforts to control diabetes and hypertension, but on the actual degree to which
they and their patients succeed in doing so. It is certainly true that
appropriate medical care bears considerable responsibility for controlled
hypertension and Hb-A1c, but the patient‘s unique condition, attitude
and ability to comply is an undeniable ingredient in producing the best
prognosis. These quality measures do not encourage good doctoring;
they incentivize doctors to choose “good” patients.
|Studies continue to suggest that PQRS raises the quality of reporting,
but does not necessarily increase the quality of care. Federman and
Keyhani  demonstrates that not more than 1 in 5 primary care
physicians found PQRS to significantly improve their quality of care
with half of the study‘s participants (including other specialties as well)
believing it had no impact on quality at all .
|An earlier national opinion-survey, conducted in 2007 , predicted
much of what is being suggested here. According to the survey, 88% of
internists believed that quality measures are not accurately adjusted
for patients‘ medical conditions and 85% believed that such measures
do not adequately account for patients‘ socioeconomic statuses.
Not surprisingly, 82% of respondents expressed concern that quality
measures of this sort would push physicians to deny care to high-risk
patients or those of low compliance. To quote one respondent directly:
|“If my pay depended on A1c values, I have 10-15 patients whom
I would have to fire. The poor, unmotivated, obese and noncompliant
would all have to find new physicians” .
|These concerns, it seems, may be well on their way to becoming
a reality. The reasons to avoid such an outcome are numerous. First,
it would undermine the purpose of the Physician Quality Reporting
System (which is to provide better care to those who need it most)
by encouraging physicians to deny much-needed care to that very
population. Second, it forces physicians into a position that is ethically
and professionally troublesome, making the moral risks equally
|One might defend this practice of discrimination by appealing
to the American Medical Association‘s (AMA) Principles of Medical
Ethics, which states that a physician (in non-emergent instances),
“shall be free to choose whom to serve, with whom to associate, and
the environment in which to provide medical care” . Based on this
alone, it would seem that discriminatory practice is in fact within the
bounds of the medical profession.
|However, the remainder of the AMA‘s code provides justifiable means to argue otherwise. It charges physicians to, “recognize
a responsibility to participate in activities contributing to the
improvement of the community and the betterment of public health”
. Further, it demands that physicians, “support access to medical care
for all people” . The practice of denying care on the basis of existing
conditions such as obesity is a breach of a physician‘s responsibility to
the betterment of public health and certainly fails to support access to
care for all people. Further, even if weight-discrimination should be
deemed a morally acceptable practice for individual physicians, the
institution of quality metrics that encourage and motivate this practice
certainly is not. These metrics discriminate against those who need care
the most and fly in the face of the fundamental mission of the Centers
for Medicare and Medicaid Services: to make quality care accessible to
all people, and precisely not to discriminate.
- Lynch HF (2013) Discrimination at the doctor's office. N Engl J Med 368: 1668-1670.
- Sabin JA, Marini M, Nosek BA (2012) Implicit and explicit anti-fat bias among a large sample of medical doctors by BMI, race/ethnicity and gender. PLoS One 7: e48448.
- Harrington R, Coffin J, Chauhan B (2013) Understanding how the Physician Quality Reporting System affects primary care physicians. J Med Pract Manage 28: 248-250.
- 2013 Physician Quality Reporting System Measures List.
- Federman AD, Keyhani S (2011) Physicians' participation in the Physicians' Quality Reporting Initiative and their perceptions of its impact on quality of care. Health Policy 102: 229-234.
- Casalino LP, Alexander GC, Jin L, Konetzka RT (2007) General internists' views on pay-for-performance and public reporting of quality scores: a national survey. Health Aff (Millwood) 26: 492-499.
- Ibid. 495
- Code of Medical Ethics of the American Medical Association (2007) Principles of Medical Ethics, Principle VI.
- Ibid. Principle VII.
- Ibid. Principle IX.