Tuesday, March 11, 2014
Program will have hospitalists identify appropriate metrics, patient attribution
by Danielle Scheurer, MD, MSCR, SFHM
We talk a lot about value in healthcare—about how to enhance quality and reduce cost—because we all know both need an incredible amount of work. One tactic Medicare is using to improve the value equation on a large scale is aggregating and displaying physician-specific “value” metrics. These metrics, which will be used to deduct or enhance reimbursement for physicians, are known as the Physician Value-Based Payment Modifier (PVBM).
This program has been enacted fairly rapidly since the passage of the Affordable Care Act; it is being rolled out first to large physician practices, then to all groups by 2017. Those with superior performance in both quality and cost will experience as much as a 2% higher reimbursement, while groups with average performance will remain financially neutral and those who show lower performance or choose not to report will be penalized up to 1% of Medicare reimbursement. This first round, for larger groups of 100-plus physicians, will affect about 30% of all U.S. physicians. The second round, for groups of 10 or more physicians, will affect about another third of physicians. The last round, for groups with fewer than 10 physicians, will be applicable to the remaining physicians practicing in the U.S.
On the face of it, the program does seem to be a potentially effective tactic for improving value on a large scale, holding individual physicians accountable for their own individual patient-care performance. A few fatal flaws in the program as it currently stands make it extraordinarily unlikely to be universally adopted by all physicians, however. Here are a few of those flaws:1,2
1 Uncertain yield: Because it is essentially a “zero-sum game” for Medicare, the incentive or penalty for a physician (or the physician’s group) depends on the performance of all the other physicians’ or groups’ performance. As a result, there is incredible uncertainty as to how strong a physician’s performance actually needs to be, year to year, to result in a bonus payment. Given that many of the metrics will require some type of investment to perform well, such as information technology infrastructure or a quality coordinator, there is an equal amount of uncertainty about how much investment will be needed to get a certain budgetary yield. For smaller physician practices, taking a 1% to 2% reduction in Medicare reimbursements may be easier to weather financially than investing in the infrastructure needed to reliably hit the quality metrics for every relevant patient.
2 Uncertain benchmarks: Unlike many hospital quality metrics, which have been publicly displayed for years, physician-level value metrics are just now being reported publicly. This leaves uncertainty about how strong a physician’s performance needs to be in order to be better than average. In the hospital value-based purchasing program, “average” performance is extremely good, in the 98% to 99% compliance range for most metrics. It is less clear what compliance range will be “average” in the physician-based program.
3 Physician variability: More than a half million physicians in the U.S. bill Medicare, and their practice types range from primary care solo practice to multi-group specialty practice. Motivating all brands to understand, measure, report, and improve quality metrics is a yeoman’s task, unlikely to be successful in the short term. Most physicians have not received any formal education or training in quality improvement, so they may not even have the skill set required to improve their metrics into a highly reliable range, worthy of bonus designation.
4 Metric identity and attribution: Because the repertoire of physician types is broad, the ability of each physician type to have a set of metrics that they understand and can identify with is extremely unlikely. In addition, attribution of patients and their associated metrics to any single physician is complicated, especially for patients who are cared for by many different physicians across a number of settings. For hospitalists, the attribution issue is a fatal flaw, as many groups routinely “hand off” patients among other hospitalists in their group, at least once if not several times during a typical hospital stay. The same is true of many other hospital-based specialty physicians.
Motivating all brands to understand, measure, report, and improve quality metrics is a yeoman’s task, unlikely to be successful in the short term. Most physicians have not received any formal education or training in quality improvement, so they may not even have the skill set required to improve their metrics into a highly reliable range, worthy of bonus designation.
5 Playing to the test: As with other pay-for-performance programs, there is a legitimate concern that physicians will be overwhelmingly motivated to play to the test, so that their efforts to perform exceedingly well at a few metrics will crowd out and hinder their performance on unmeasured metrics. This tendency can result in lower-value care in the sum total, even if the metrics show stellar performance.
6 Reducing the risk: As seen in other pay-for-performance programs, there is a legitimate concern that physicians will be overwhelmingly motivated to avoid caring for patients who are likely to be unpredictable, including those with multiple co-morbid conditions or with complex social situations; these patients are likely to perform less well on any metric, despite risk adjusting (which is inherently imperfect). This is a well-known and documented risk of publicly reported programs, and there is no reason to believe the PVBM program will be immune to this risk.
Because these flaws seem so daunting at first glance, many physicians and physician groups will be tempted to reject the program outright and take the financial hit induced by nonparticipation. An alternative approach is to embrace all of the value programs outright, investing time and energy in improving the metrics that are truly valuable to both patients and providers.
Regardless of which regulatory agency is demanding performance, we need to be active participants in foraging out what metrics and attribution logic are most appropriate. For hospitalists, these could include risk-adjusted device days, appropriate prescribing and unprescribing of antibiotics, judicious utilization of diagnostic testing, and measurements of patient functional status and/or mobility.
Value metrics are here to stay, including those attributable to individual physicians; our job now is to advocate for meaningful metrics and meaningful attribution, which can and should motivate hospitalists to enhance their patients’ quality of life at a lower cost.
A J.D. Power study placed AvMed Health Plans and Humana in a tie for highest member satisfaction among Florida health plans.
The Westlake Village, Calif.-based company measures member satisfaction for the largest health plans in 18 regions using a 1,000-point scale.
The average customer satisfaction score across all regions was 669, but the Florida average came in a little below that, at 664. Both AvMed and Humana scored 690, which is considered five out of five stars. It’s the third consecutive year AvMed’s been at the top.
“At AvMed, we’re committed to building a unique member experience that we feel only we can deliver,” said James M. Repp, senior VP of the Miami-based health plan. “Working with our providers, we’re putting the members at the center of the health care experience, exactly where the member belongs.”
The J.D. Power study ranked AvMed high for provider choice, claims processing, cost and coverage. Humana received high rankings for communication, customer service and coverage.
The other Florida plans rated by J.D. Power were Cigna (680), Florida Blue (677), Aetna (649), UnitedHealthcare (646) and Aetna subsidiary Coventry Health Care (602).
Cigna received high ratings for provider choice and coverage. Florida Blue was above average in most areas. UnitedHealthcare scored below average for customer service. Aetna scored below average for both cost and coverage. Coventry scored below average in all areas.
DAYTONA BEACH — Halifax Health must pay the U.S. Department of Justice $85 million within 10 days and operate under a corporate-integrity agreement for five years to resolve allegations that it broke a federal law meant to stop Medicare abuse, according to a settlement agreement filed Monday in federal court in Orlando.
Halifax Health says the settlement is not an admission that it committed fraud by submitting false Medicare claims to the government. The agreement states the hospital admits no liability in the settlement, except that it violated the Stark Law, which bars paying doctors based on referrals and volume.
Another part of the case involving allegations of unneeded admissions to the hospital is set for trial in July.
“We believe we have a fiduciary responsibility to avoid the risks associated with trial and the potential of a lengthy appeals process,” John Guthrie, a Halifax Health spokesman, said in a prepared statement. “We will continue our mission of providing exceptional patient care and providing health and wellness services to our community as the only safety-net hospital in the area.”
Elin Baklid-Kunz, the hospital's director of physician services, filed the whistle-blower lawsuit in 2009 accusing the hospital of maintaining illegal contracts with doctors and billing the federal government for unnecessary medical procedures. Baklid-Kunz and her attorneys will receive 24.5 percent of the settlement amount — about $20.8 million. Baklid-Kunz, who still works for the hospital, earns an annual salary of $92,081, according to hospital records.
The Justice Department accused Halifax Health of overpaying six cancer doctors and three neurosurgeons and submitting false Medicare claims. When the Justice Department joined the case, it said in a statement it was doing so because employment agreements such as the ones structured by Halifax Health can lead to unnecessary medical procedures and health care expenses.
In the settlement, the federal government maintains the merits of its accusations. Assistant U.S. Attorney Ralph Hopkins declined comment about the case Monday afternoon. A Justice Department spokesman said a statement would be forthcoming.
Halifax Health's employment contracts and business practices will be under greater scrutiny as a result of the corporate-integrity agreement in the 17-page settlement. The agreement includes federal oversight of all physician contracts, Guthrie said.
Last week, Halifax Health officials said the settlement would not include an admission of wrongdoing, and the public hospital with taxing authority would pay the settlement amount over a period of several years through “belt-tightening and the potential delay of capital expenses,” instead of raising taxes. The hospital system has poured more than $21 million into its legal defense so far.
In the agreement filed Monday, though, Halifax Health admits it violated the Stark Law, and the hospital is required to pay the money in the next 10 days — instead of over a period of several years. Halifax Health has about $420 million in cash reserves, while carrying about $348.2 million in long-term debt, according to a recent review by Standard & Poor's rating agency.
Halifax Health officials deny the hospital's doctors performed unneeded procedures and say they tailored the agreements with the intention of keeping critical doctors in the community.
The settlement does not include another part of the suit involving allegations that the hospital admitted patients for unnecessary inpatient stays of two days or less, instead of treating them on an outpatient basis. That matter is set for trial in July and carries potential damages and penalties of more than $240 million. The government did not intervene on those claims. The whistle-blower's attorneys are also entitled to ask for fees and costs related to the case.
“Halifax has not put this case behind them,” said Marlan Wilbanks, an attorney for Baklid-Kunz. “We think the biggest part of the case is left in front of them.”
Halifax Health has consistently denied the whistle-blower's allegations.