From reddits [–]a_real_MD Doctors pay will be determined by the quality of their care, not how many people they treat. Doctor here. Im seeing a lot of questions about how exactly this will be implemented and what it will mean for physicians and patients. I will do my best to explain whats already happening, and what will happen in the future. The basic idea is that there will be an established list of ideal care criteria that must be met, and reimbursement will be adjusted accordingly. This is already happening, but in a different form. What we have now There are several groups that come by to certify and accredit hospitals based on a set of national guidelines. The major group for Hospital accreditation is the much-feared Joint Commission (jointcommission.org/standards_information/npsgs.aspx) who comes by every so often and performs an intensive review of the hospital and its policies and outcomes which are then compared to their National Patient Safety Goals. Public quality reports are generated based on their results and accreditation is granted. Here is the public report for UCSF, for example: qualitycheck.org/qualityreport.aspx?hcoid=10095#comparative. They identify deficiencies and mandate swift policy changes to ensure adherence to guidelines. Even more feared and applicable is CMS, The Centers for Medicare and Medicaid Services (cms.gov/). CMS also comes by and performs an intensive review of the hospitals outcomes and adherence to nationally established safety guidelines. For example, as part of the SCIP (Surgical Care Improvement Project), they will look at how often patients received their dose of pre-operative antibiotics within 1 hour prior to incision. CMS knows what the national average adherence rate among hospitals is and thus, can quickly identify centers that are not compliant. Non-compliant centers are generally notified of their deficiencies formally and then must quickly remediate or risk losing Medicare/Medicaid reimbursements, the loss of which would essentially kill any hospital. The reason I mention these groups is because they are already beginning to extrapolate on their national data collection programs, as I will detail below. Whats to come The nationalized accreditation and quality monitoring groups such as CMS and The Joint Commission already know how well hospitals are doing regarding established patient safety measures. Whats next is the providers. Already, mandatory reporting regarding provider outcomes is beginning. For example, Dr. Johnson, who is a Surgeon, will have to report his average operative time for a cholecystectomy and his post-operative wound infection rate. If he falls below a certain percentile nationally, his reimbursement will be negatively affected. If he is in say, the top 10% nationally, he will receive a small bonus (this is the tentative plan as Ive heard it from the higher-ups at my hospital). How this will work for primary care is a little murkier. The general consensus seems to be that they will try to reimburse based on a similar set of nationally defined quality measures like they are using for hospital accreditation, Medicare center status, etc. For example, is Dr. Smith keeping his patients HbA1C below 7.0%? (An indication of good long-term diabetes control). Is he keeping his patients LDL less than 100? So on and so forth. This all seems like a great idea on the surface, but without putting my own opinions into this, I offer the following scenarios for your consideration: Dr. Smith and Dr. Johnson are both primary care physicians. They both have 10 identical patients with diabetes, for whom each physician prescribes the exact same, evidence-based, standardized diabetes protocol. 4 of Dr. Smiths patients are non-compliant with their insulin regimens, despite optimal counseling and the best efforts of Dr. Smith, thus their HbA1C values will be above the cutoff that qualifies them for a good outcome. In the end, medication compliance is a patient choice which cannot be controlled by the physician and although Dr. Smith did everything right from a medical standpoint, those patients will be red-flagged and reimbursement decreased. Dr. Unlucky is a cardiologist, and Bill is a patient of his with Congestive Heart Failure. Bill is receiving the evidence-based optimal medical management for his CHF (Carvedilol, ACE inhibitor, etc). Bill has been counseled extensively on the importance of a low sodium diet and careful fluid intake because of his CHF. Bill is a Cleveland Browns fan and they make it to the Superbowl for the first time since god only knows. Bill has a Superbowl party with his buddies and eats a ton of potato chips and drinks a few beers and ends up in the hospital with a CHF exacerbation. Dr. Unlucky is now dinged for a hospitalization for CHF exacerbation for a patient under his care, which will be reported and affect his pay. Its situations like this that are worrying physicians. I urge you to remember these are just example scenarios, to give you, the reader, pause to consider what could be a greater problem. What criteria will comprise these quality of care outcomes remains to be seen, so no one knows yet exactly how it will look, but believe me when I say that its not the mandate thats the game-changer, its what Ive discussed above. This will fundamentally alter the face of the medical field, whether its for better or for worse remains to be seen. Hopefully this was helpful.
Posted on: Sun, 27 Oct 2013 16:36:12 +0000
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