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Transcript of CMS Innovation Advisor Project Representing Group 4 Richard Young, MD Director of Research John...
CMS Innovation Advisor Project
Representing Group 4
Richard Young, MDDirector of ResearchJohn Peter Smith Hospital FMRPFort Worth, [email protected]
Group 4 – The Island of Misfit Toys
My Project - Background People from the middle of the
country, especially medium and small communities quickly understood my project.
People from large cities, particularly the Washington DC to Boston corridor did not understand my project.
Three Problems
National shortage of primary care physicians
Onerous primary care documentation, coding, and billing rules
Patients with the most chronic diseases cost the most to care for
Why Worry? – Primary Care
Texas
Ologist Supply - Quality
Ologist Supply - Cost
Family Physicians - Quality
Family Physicians - Cost
Another Model: WeCare
• Example from a manufacturing facility in Indiana
• 1,100 employees 2,300 lives
• One-year savings: $4 million• Net clinic
costs
Summary – Better Quality and Lower Costs It’s an issue of physician supply
But little interest in adult ambulatory primary care among U.S. medical students– 8% family medicine– 2% general internal medicine (if
that)
Why the Lack of Student Interest?
Second Problem
Onerous Evaluation and Management (E/M) documentation, coding, and billing rules.
HCFA created these rules in 1995 then 1997
Reason? -- Fraud and Abuse No vetting, validating, piloting
E/M Rules
In 2002, an Advisory Committee on Regulatory Reform of the U.S. Health and Human Services Department reviewed these guidelines
An advisor for HHS Secretary Tommy Thompson concluded, “documentation guidelines are the poster child for regulatory burden.”
Voted 20-1 to eliminate the payment rules.
CMS E/M Rules – Example
From the Risk Table:
The CMS Document
89 pages!!
And There’s More
Another 100 Pages
Third Problem –Chronic Disease Costs
My Project - Assumptions Interest in primary care among
medical students will not increase until the income disparity is fixed.
Existing CMS documentation, coding, and billing rules are the primary cause of the income disparity.
My Project -- Assumptions Better U.S. primary care supply to
take care of everyone, especially patients with multiple chronic diseases, leads to:– Better health– Better patient experience– Lower costs
What is My Project?
To throw away the existing CMS E/M documentation, coding, and billing guidelines and start all over.
Driver Diagram
Ologies
Adult Primary Care
Medical Students
$
More Assumptions
The solution is NOT to pay family physicians $200 for a sore throat.
The solution is to pay family physicians for all the work they do that currently isn’t paid for.– Literature: 20%-50% of work NOT
paid Align incentives to achieve better
efficiencies and outcomes.
My Previous Research
Family physician cost-effectiveness– Article to be published in Family
Medicine this spring. Family physician opinions of
current system– Manuscripts in progress
Project Development
Formed advisory/feedback team– 23 family physicians
Survey - Listed 28 units of work not currently explicitly paid under current system
Vote for:– Paid as a separate fee– Paid as a global fee– Just part of our job
More Supporting Work
Surveyed doctors in other countries about their documentation, coding, and billing rules.– U.S. is the only country that ties
documentation to payment
Solution - Principles
If the physician can’t tell a computer what he or she did, then he or she won’t get credit for the work.
New system – Clinic work is additive– One issue = small bill– Many issues = big bill
Incentivize primary care to provide as comprehensive care as possible.
Solution - Principles
Incentives– No incentive to order tests– No incentive to order treatments
Both of these incentives exist in the current system.
My System Innovations – Documentation Chronic diseases
– Effect on Quality of Life– Effect on Functionality– Adherence and Tolerance to Medications– Pertinent Physical Examination– Pertinent Lab/X-ray results– Maximal Medical State (Treatment Goal)– Treatment Plan
New System – Coding
Issues Addressed code -- IA.x Becomes primary code
– Replaces existing CPT codes (99213, etc.)
3 Levels– 3, 2, 1– Level billed is a function of
Thoroughness and primary care Responsibility
New System – New Codes and Fees (a few examples)
Work Requiring Extra Time– Example: Advance Directive Discussions
Global Fees (care coordination)– Different approach
Non-Face-to-Face Work– Emails, phone calls, text messages
Discourage ExcessiveUtilization - Professionalism Few Examples:
– Clear statement that one of the goals of primary care is to be a good steward of medical resources
– Use generic medications whenever possible
– Spread out visits for patients with stable chronic diseases
Validation of This System I observed family physicians in
private practices I recorded
– Times– Number of Issues Addressed– Which issues addressed– Procedures, referrals, expensive
tests ordered, labs, X-rays, etc.
Typical Practice Avg. visit length 17.5 min. Avg. # issues/visit 3.5 Issues Addressed
– Thorough 0.8– Moderate 1.8– Brief 0.9
Avg. # Tests and RXs 1.6 1.0 Avg. Fee Collected $99 Avg. New System Fee $117
Typical Practice
Declined patient requests for services – $3 declined services for each $1 of
revenue Some unnecessary services
– About $1 unnecessary services for $1 revenue
– My system includes incentives to lower this amount
Validity - # Issues Good agreement between me
and observed physician for number of issues addressed in each visit
0 1 2 3 4 5 6 7 80
1
2
3
4
5
6
7
# Issues Addressed Count
My Count
Observed Physician's
Count
R2 = 0.66, P< .001
Complete Agreement
Validity – New Fee vs. # of Issues Addressed
$40 $60 $80 $100 $120 $140 $160 $180 $200 $220 $2400
1
2
3
4
5
6
7
8
Number of Issues vs. New Fee
New Fee
# of Issues
R2 = 0.77, P<.001
Examples – Quick Visit
Example: Longer Visit
* Existing CMS fees
Comparison to Multi-Doctor ApproachIssue Doctor CMS Current Fee*
Migraines Neurologist $103
Hypertension Cardiologist $69
High Cholesterol Lipid-ologist $69
Foot Pain Podiatrist $158
X-Ray Radiologist $52
Low Back Pain Orthopedist $69
Preventive Care Family Physician
$131
Post-Menopausal Bleeding
Gynecologist $267
TOTAL 8 $918* Assumes no facility fees
Modeling of New Approach: Effect on Physician Income Income under existing rules/fees
– $169,000 Income under my new approach,
no change in practice style– $245,000
Income assuming FP is a little more thorough– $283,000
Effect on Physician Income Income assuming more thorough
plus capture more non-face-to-face fees (emails, phone calls, etc.)– $326,000
Income assuming above plus other incentives to provide full basket of services and not overtest or overtreat.– $417,000
Run Chart
Finally
Lessons Learned– Colleagues for life: Others looking
for answers with passion and commitment
– I know more about change management and process improvement
Barriers Total Cost Data
– CMS: ResDAC data help– My local intermediary disappearing
(Trailblazer) Funding for experiment
– Myself– JPS Health Network
Still might happen– CMS
No luck with regional office so far
Next Steps
Another cycle of observations to further validate payment model.
Present model to AAFP CMS – Could start using this
system now!!
Finally
Thank you Fran Thank you mentors Thank you fellow Innovation
Advisors
Goodbye from the Island of Misfit Toys