For a Few Dollars More
Over the last several days I have been pouring myself into the latest information from CMS on what lies ahead in the world of quality – that being the proposed rule on Value Based Purchasing as published in the Federal Register. As with most things that the government produces, I prefer to read the original text, not only the summaries, as many of the finer details tend to get overlooked.
As I dug into the first page, I was actually a bit encouraged. We all know that quality will be included in whatever form of reimbursement is on the horizon and CMS’s approach sounded reasonable.
Scoring methodologies should be reliable, as straightforward as possible, and stable over time and enable consumers, providers and payers to make meaningful distinctions among provider performance.
Makes sense to me. Then I read on….
After a 7 page description on why the metrics chosen were the most appropriate metrics, CMS goes on to dedicate a full 20 pages of the 39 page rule to describing the proposed scoring system, including a discussion of the use of "cube versus linear models" of the exchange function to determine ultimate distribution of payments among hospitals. It reminded me a bit of my vector physics classes from undergrad, but a little less understandable.
As those of you who know who know me well, I am in full support of integrating the measurement of quality into any reimbursement model. However, by trying to so fully objectify this measurement, it appears as if CMS has created (or at least proposed) a system that is begging to be gamed by those that participate in it. How long will it take for vendors to begin promoting “key indicators” that, if focused on and improved, will lead to greater reimbursement? And even if these “key indicators” are met, will we really see any appreciable improvement in quality of care? By focusing on payment reform first and care delivery reform second, we are once again creating another model of measurement rather than a model of improvement.
I don’t have all the answers, but I do believe as do many of my colleagues, that for any new delivery system to succeed, there will need to be a greater degree of collaboration between physicians and hospitals. If a measurement system of this complexity is ultimately implemented, it may very well lead us to the law of unintended consequences. By focusing on the details of the payment system and not the improvement of the delivery system, we make it more difficult, if not impossible, to achieve the integration, alignment, and redesign necessary to build the new delivery system that we can all agree is sorely needed.
Mark - great piece. While I totally agree with you about the importance of addressing quality, I want to dive a bit deeper into your last concluding point on not focusing on payment and focus more on the delivery system. We have known for some time that our system is broken. Some may say fragmented beyond repair. This fragmentation drives up cost. The delivery system needs to immediately be addressed for us to ever come close to bending the cost curve. There are ways to reorganize the system to improve performance (and quality) see here: http://bit.ly/xNwQ as an example. Yet we know that there cannot be one single way to fix the delivery system because of the variance in population served, workforce availability, etc. Better integrating systems is one way to "defragment" see here for another example: http://bit.ly/ghcVTW So to get to my point, payment reform can help shape how we "behave" in a broken system. Your last paragraph points out the need for physicians and hospitals to collaborate to a higher degree, but what happens when your collaboration is based on a flawed business model? If you change the way you pay for services (payment reform - http://bit.ly/2VKwnu ), and move away from fee for service models, then providers (and hospitals) may have the flexibility to behave differently. Regardless of which end you start (system or payment), both need to be addressed. Why not do it simultaneously?
We should consider such changes as:
-Incenting primary care through strategies like the “patient-centered medical home”
-Consider the role of integrated health delivery organizations and innovative payment schemes like global capitation
-Bundle payments (episodes of care) to better coordinate healthcare and improve outcomes
-Integrating mental health and "physical health" as the separation continues to drive up costs and lead to inferior care
Ben,thanks for the great insights and comments. I agree that both payment reform and care reform are necessary and can happen simultaneously, but we need to balance the scales a bit and get the innovative care models out there. My post tomorrow is all about some of those new emerging care models. I look forward to your thoughts on it.
-Mark
I think I can write an entire essay on this subject, but of course, I won’t.
Here is the bottom line though, it is virtually impossible to create meaningful distinctions among provider performance.
There are many reasons why it is not possible, but one that sticks out the most for me is, providers are dealing with one huge, huge variable called “humans;” whom are largely unpredictable. Not to mention that at least in the United States, have terrible healthy lifestyles.
What would be the incentive for a provider to treat a very ill patient or patients with a less than optimal prognosis?
What if a provider insisted on a treatment, but the patient refused it?
What if the patient and the doctor agree on a treatment, but insurance companies denies the treatment?
What if despite the insistence of their pediatrician, parents of a child disregarded their PCP advice to control the patient’s asthma and after waiting too long for treatment rush their child to the ER with respiratory distress and the doctor at the ER is unable to save the little girl. (True story by the way).
Also, how would one measure when a doctor, with treatment, expertise, guidance, etc helps patient avoid or recover from a life threatening illness? How much should we pay the doc for that?
Why is it that when the doctor does his job right, he is paid so little, but when he does his job wrong, he pays so much?
“Scoring methodologies should be reliable, as straightforward as possible, and stable over time and enable consumers, providers and payers to make meaningful distinctions among provider performance.”
Here is the problem with this statement… the only ones that are held accountable is the “provider.”
@pediatricInc
@pediatricinc: you have hit the nail on the head. Less authority, more responsibilty and less reimbursement.