More evidence shows that medication is often just as effective as an artery-opening angioplasty for patients with chronic chest pain. Although angioplasty remains the top treatment for such patients, the number of those performed has declined since 2007.
Physician practices do not always realize the level of change necessary to successfully implement and use a pay-for-performance (P4P) program. Before you can see the benefits of P4P, you first have to weave through some obstacles and find new ways to approach quality performance.
One of the obstacles many physicians face when starting a P4P plan is changing the practice's perspective of clinical care to match set requirements. Consider these three steps to resolve this issue:
1. Restructure your practice. Meet with the front office staff and educate them about this program. Teaching staff members the measurements will help doctors achieve their performance. For example, staff members need to know which patients have diabetes in the office. They need to know what specialist to refer the patient to, and they must give clinical staff members the proper follow-up information for a particular patient.
2. Organize physician notes. Practices' patient information system need to be redesigned to show patients' demographics, such as weight, height, age, and medication documentation.
For example, group all the major diabetes medicines by blood pressure and cholesterol.
3. Implement a health maintenance profile. The profile could be a list of metrics for a diabetes patient, including dates for his or her flu shot, when he or she needs to see a specialist, and when the previous blood work appointment was made, for example. Be sure to update these regularly.
P4P can be complicated to understand and requires the practice and its physicians to change their perspectives of care in order to see rewards. Consider the following questions before diving into a commitment.
Can this plan help with quality of care in my practice? Do the cost benefits add up in my favor? Am I ready to change?
What conditions and protocols or procedures will I measure with this P4P program?
Who will analyze the charts, data, and patient information to measure my performance accurately and according to the plan?
This article was adapted from one that originally ran in the August issue of The Doctor's Office, a HealthLeaders Media publication.
Editor's Note: In this monthly forum, attorney Jim Saxton (Stevens & Lee, Lancaster, PA) answers your questions about risk management and liability reduction and provides practical, how-to information on risk-reduction strategies.Dear Jim,
I have just gotten flooded with emails and concerns about the so called "never events." As I read through from a commentary, I actually find myself getting more concerned. Is this one of those trends that is going to quickly fade in and out?
Betty Jones
Hospital Risk Manager
Dear Betty:
Let me make a fairly broad statement here. I think we should refrain from using the phrase "never events." Never, as defined by a standard dictionary, is an event which "on no occasion can occur," "cannot happen." I am at a loss to know how that concept applies to occurrences in hospitals such as falls or bed sores.
Wouldn’t it be more appropriate, as to some of these occurrences, to refer to these events as "reducible safety issues?" There is little doubt that greater emphasis should continue to be placed on reducing medical errors and unsafe circumstances. This is a complex subject and there are many facets to it. However, the thought that a fall in a hospital should never occur would appear to be flawed. There will be significant financial implications, but this column is not the time to discuss the reimbursement and financial implications. However, there are also clearly liability implications.
We need to remember that the lay public who are reading about these "never events" are our jurors. The sound bites and headlines actually make it sound more than shocking that these events can occur. Let me make it clear that I am firmly onboard with the safety movement. Much of the work of our team has been dedicated to promoting the same. I just think concurrently we have to be evaluating the pragmatic risk management issues.
For now, you should make sure that your committees within the hospital are carefully reviewing the way these events are described. They should carefully look at the reimbursement implications and how communications with patients or family members will occur. You should certainly begin to sort out what is a reimbursement decision (a third party payer’s decision not to reimburse a certain service) and an evidentiary issue which may occur in the courtroom. Your lawyers will be able to address the latter.
This change in reimbursement policy should not be meant to establish a near perfect (or perfect) standard of care. Many plaintiff attorneys would try to argue that these occurrences are negligence or worse. I would argue that that certainly is not the case and, in fact, plan on filing appropriate motions so that terms like "never events" are not even used in court. We need to be prepared to articulate our positions as the first set of legal rulings take place, and appeal when necessary. Those first, well thought-out decisions as to what "never events" mean will be important.
Let’s continue this effort in the name of safety but not assume that this is a reimbursement issue only. If we do, our liability insurers will be paying for known complications of procedures and you will see the soft market harden pretty quickly.
A bill signed into law this week in New York now allows officials to publicly identify physicians who have been charged with misconduct or malpractice. It also gives the state Department of Health the power to investigate medical wrongdoing. The new law was prompted by a doctor who was accused of malpractice in 2004.
An increasing number of hospital administrators throughout California are working hard to reduce medical errors, as state officials continue pushing for better quality care and patient safety. Since the state Department of Public Health began issuing fines for preventable errors, 39 hospitals have been cited for such mistakes.
It seems that all we hear about primary care these days are dire warnings about low reimbursement and physician shortages, so I want to start out with some good news for a change: Compensation for primary care physicians increased nearly three times as much in 2007 as it did in 2006, and it outpaced compensation increases for specialists (combined) for the second straight year.
That sounds great, but here come the caveats. The numbers only sound impressive because the bar has been set so low. Primary care compensation increased about 6.3%, according to MGMA's latest Physician Compensation and Production Survey. That is the biggest increase primary care doctors have reported in years.
Specialty physicians also reported a bigger jump in compensation than last year, but again, that's because the previous increase was so low (less than 2%). Although some specialists did very well—invasive cardiologists, anesthesiologists, urologists—overall, compensation for specialty physicians barely kept pace with inflation.
So does this mean primary care is starting to "catch up" to specialty care?
"We are seeing a market adjustment where the market is starting to move back toward placing importance on primary care," says Crystal Taylor, MHA, MGMA's assistant director of survey operations.
Supply and demand forces, as well as CMS' efforts to increase reimbursement for evaluation and management codes, are certainly helping out, she says. But whether this is the beginning of a major market shift or just temporary "good news" remains to be seen.
The increases certainly aren't enough to reverse the shortage problem. Take internal medicine. With the latest increase, median compensation for internists is about $190,547. But a physician with the same training could earn $197,872 as a hospitalist, and probably work fewer hours.
Almost any other specialty a physician can choose when leaving medical school is more lucrative than primary care, and as long as that is the case, the shortage will only get worse.
Although the market is beginning to recognize the value of primary care, its problems can't be fixed in increments or by market forces alone. If supply and demand were the only factors influencing how much physicians are paid, I'd venture to guess that we'd be seeing double digit increases for primary care at this point.
But there's only so much practices can do to increase what they pay primary care doctors under a fee-for-service system. Their services simply aren't valued, and it's going to take a major change in the healthcare reimbursement system to fix primary care's problems.
Elyas Bakhtiari is a managing editor with HealthLeaders Media. He can be reached at ebakhtiari@healthleadersmedia.com.
Note: You can sign up to receive HealthLeaders Media PhysicianLeaders, a free weekly e-newsletter that features the top physician business headlines of the week from leading news sources.