After completing Stage 1, Dr. Khan’s oto-
laryngology group is evaluating whether it’s worth proceeding to Stage 2 because the one-size-fits-all scheme leaves little room for the practice to adapt as it sees fit to ac- tually achieve the quality improvements Medicare wants. “Do I take a penalty, or fundamentally change how I practice in a way that’s not good?” Physicians also worry about getting pe- nalized for factors beyond their control. Ms. Kinney says Medicare’s payment cal-
culations under the VBM do not adjust for risks such as patient noncompliance, pov- erty, or other demographic factors shown to affect quality and costs. That puts physi- cians treating the sickest patients at a real disadvantage. In fact, according to AMA’s letter, “a CMS contractor found that physi- cian groups with the highest risk patients were three times more likely than average to have poor quality scores and four times more likely to have poor cost scores.” Medicare’s methodology also holds phy-
sicians responsible for care their patients receive elsewhere. For example, Medicare assigned the costs for 1,350 surgical visits to the surgeons in UMC Medical Center’s multispecialty practice, even though half of those visits were handled by physicians or organizations outside the UMC group. A third of the specialty care visits and the associated costs assigned came from else- where, too. “Medicare patients can choose to go
wherever they want. And if I’m a primary care guy trying to manage costs, and pa- tients are going to a cardiologist outside the system who may order all kinds of test- ing, I have very little control over that,” Dr. Ragain said. “I’m happy to be responsible for the costs that are attributable to me. I’m not so happy to be accountable for the costs attributable to everybody else.”
WHAT IS ORGANIZED MEDICINE DOING TO ADDRESS THESE ISSUES?
ARE MEDICARE AND CONGRESS LISTENING? TMA and AMA continue to advocate to Medicare and Congress for needed changes to these programs, with some success so far. Meanwhile, TMA has developed a host of
April 2015 TEXAS MEDICINE 33
ALPHABET SOUP
PQRS: Physician Quality Reporting System Medicare program requiring physicians to document and report on clinical quality measures. Scores feed into the VBM, value-based payment modifier (see below).
MU: Meaningful use Medicare’s electronic health records incentive program.
VBM: Value-based payment modifier
Medicare calculation to adjust physician fee-for-service payments either up or down based on how they perform on cost and quality factors.
CAHPS: Consumer Assessment of Healthcare Providers and Systems Patient satisfaction and experience surveys.
QRUR: Quality and resource use report
Medicare feedback reports on physician quality and cost scores and how they compare to their peers.
SGR: Sustainable Growth Rate Medicare formula to calculate physician fee-for-service payment rates.
MIPS: Merit-Based Incentive Payment System Alternative value-based payment system proposed under draft SGR repeal legislation that combines these current programs: PQRS, MU, and VBM.
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