Download Young Group 4 IAP projects 9-12

CMS Innovation Advisor
Project
Representing Group 4
Richard Young, MD
Director of Research
John Peter Smith Hospital FMRP
Fort Worth, Texas
[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
Medical Students
Ologies
$
Adult
Primary
Care
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 Excessive
Utilization - 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
Avg. # issues/visit
Issues Addressed
– Thorough
– Moderate
– Brief



Avg. # Tests and RXs
Avg. Fee Collected
Avg. New System Fee
17.5 min.
3.5
0.8
1.8
0.9
1.6 1.0
$99
$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
# Issues Addressed Count
Complete
Agreement
7
6
5
Observed 4
Physician's
3
Count
2
1
0
0
1
2
3
4
My Count
R2 = 0.66, P< .001
5
6
7
8
Validity – New Fee vs.
# of Issues Addressed
Number of Issues vs. New Fee
8
7
6
5
# of Issues 4
3
2
1
0
$0
$50
$100
$150
New Fee
R2 = 0.77, P<.001
$200
$250
Examples – Quick Visit
Example: Longer Visit
* Existing CMS fees
Comparison to MultiDoctor Approach
Issue
Doctor
Migraines
Neurologist
$103
Hypertension
Cardiologist
$69
High Cholesterol
Lipid-ologist
$69
Foot Pain
Podiatrist
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
CMS Current Fee*
$158
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