Bob Matthews

October 10, 2018

The Real Money Shot

Medisync Blog

As we all know, healthcare providers are experiencing a dislocating change in how they make money. We’ve all endlessly read and heard about the “volume to value” transition. We keep asking, “When and how?”

A decade or more ago, early in this transition, many contracts had quality bonuses, an early form of value. Because it was difficult or impossible for insurers to see the real quality of care, insurers used an easier proxy which was to pay physicians based generally upon meeting process measures.

For example, if you had a diabetic patient and performed a foot exam each year, did at least two A1c blood tests in a year or had records of an annual retinal exam, you got rewarded. One enthusiastic regional carrier, Blue Cross Blue Shield of Massachusetts provided a substantial bonus to physicians who participated in this type of a program.

As time went on it became clear – and studies showed – that these process measure had no correlation what-so-ever to actual patient costs or outcomes. The problem was that the provider was paid for poking diabetic feet with something sharp. Payment per poke, as it were. However, the provider could document that the foot slowly turned black and fell off the ankle and still get paid for higher quality. Similarly, a doctor could do two A1cs that showed blood glucose averages of 12 but s/he was paid because the rewards were premised on process actions, not actual outcomes.

The “money shot” in diabetes is, of course, to get the blood pressure down, the lipids treated and the blood glucose levels as low as possible without inducing hypoglycemic events. If you do those things, the foot is likely to remain pink and the patient generally healthier.

What BCBS of Massachusetts learned was that it paid a lot of money for no real benefit to the patient’s health status and, thus, without reducing the total cost of care. Physicians got the impression, based upon experience, that quality rewards were easy and lucrative even if the patient didn’t benefit.

This summer there was a lot of consternation about a proposed CMS change in the E&M documentation regulations. Physicians complained, in responses to an earlier CMS Request for Information, about the burdens of documenting the history of the present illness, the review of systems, the physical exam, etc. in order to be paid for a higher E&M code.

Unfortunately, in their effort to make documentation simpler, CMS proposed that a patient seen for a head cold would generate the same fee as a patient who appeared with diabetes, renal disease, heart failure, COPD, etc. This caused a hue and cry among providers and it looks as though CMS will have to back off that proposal.

A quick note about the CMS proposal. Years ago we spent some time making it as easy as possible for our doctors to document their care and to correctly assign E&M codes with confidence. There were two outcomes: (1) our medical records became immeasurably better organized and clearer and (2) it took no more time to do a great record than before. In fact, in some instances it took less time. Had the CMS proposal gone through, we had already decided not to change a thing in our documentation process. We didn’t want to weaken our quality or expose ourselves to greater medical – legal jeopardy.

Increasingly, as CMS proceeds with its quality effort, physicians now have a lot of make work, “check box” process steps as a proxy for quality. We document that we had shared decision making, we document that we gave the patient a summary of his/her visit, etc., etc.

These are not steps that are going to reduce the total cost of care or to increase the quality of care. If CMS wants to truly engage physicians and medical groups to improve outcomes and reduce cost it must find meaningful ways to track what really matters. Outcomes matter. Outcomes can be expressed in total cost issues – admits, ER visits, re-admits, etc. Outcomes can be involved in true control for the major chronic diseases – lower blood pressures, lipids, blood glucose and greater control for asthma, COPD, heart failure, etc. are the goals.

We want to be paid for doing a better job for patients. CMS should be focused on making that kind of payment plan possible.



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