Physi­cian pay sys­tem re­wards qual­ity

Mis­cal­cu­la­tion shows new model un­der­go­ing grow­ing pains


A key part in the way the United States is chang­ing how it pays for health care is feel­ing some grow­ing pains.

The grind­ing and stretch­ing comes now just a few months be­fore the gov­ern­ment starts re­ward­ing physi­cians for meet­ing per­for­mance stan­dards and pun­ish­ing those who don’t un­der the Merit-based In­cen­tive Pay­ment Sys­tem or MIPS.

Par­tic­i­pat­ing doc­tors have been go­ing through the mo­tions for the last two years, self-re­port­ing on whether and how well they meet per­for­mance stan­dards. Whether they do de­ter­mines if they get a boost in Medi­care Part B re­im­burse­ments or pay a penalty.

How­ever, an er­ror in how the Cen­ters for Medi­care and Med­i­caid Ser­vices cal­cu­lated doc­tors’ 2017 scores, now be­ing cor­rected, will change the amounts doc­tors thought they were to re­ceive in bonuses or pay in penal­ties be­gin­ning next year.

The MIPS sys­tem is de­signed to be bud­get neu­tral, so it can’t cost Medi­care ad­di­tional money, ex­plained Dr. Jaan Si­dorov, pres­i­dent and chief ex­ec­u­tive at the Care Cen­tered Col­lab­o­ra­tive, a for-profit arm of the Penn­syl­va­nia Med­i­cal So­ci­ety that works as a li­ai­son be­tween pri­vate in­sur­ance com­pa­nies and doc­tors to bet­ter de­fine health care qual­ity stan­dards and how much meet­ing them is worth.

“The bonus money is spread like peanut but­ter across the en­tire pop­u­la­tion,” he said of the MIPS re­im­burse­ments to doc­tors. “Be­cause those er­rors oc­curred in a bud­get-neu­tral pay­ment pro­gram, every­body’s pay­ments have to change.”

For many doc­tors, the change means they could re­ceive a few thou­sand dol­lars less in their re­im­burse­ments.

“That’s not, from a busi­ness point of view, a whole lot of money,” he said. “We’re talk­ing about sin­gle-digit per­cent­age swings.”

The CMS is giv­ing doc­tors un­til 8 p.m. Mon­day to re­quest an in­di­vid­ual re­view if they be­lieve the agency made mis­takes in cal­cu­lat­ing their scores.

What does all that mean for pa­tients?

Di­rectly, not much. The mis­cal­cu­la­tion rep­re­sents an­other stitch in the na­tion’s glacial shift to­ward pay­ing for good health rather than pro­ce­dures and vis­its. The MIPS re­im­burse­ments rep­re­sent a small slice of a par­tic­i­pat­ing doc­tor’s to­tal in­come, but even­tu­ally, Medi­care would like to see all health care paid for based on re­sults.

The United States spends more on health care per ci­ti­zen than any other coun­try, more than $9,200 per per­son, ac­cord­ing to re­search pub­lished last year and funded by the Bill and Melinda Gates Foun­da­tion.

The CMS see re­ward­ing doc­tors for health­ier pa­tients, not sim­ply for the num­ber of pro­ce­dures or vis­its they amass.

Since Medi­care sets the pace for the na­tional health in­sur­ance in­dus­try, in­sur­ers are cer­tainly watch­ing to see how other pay­ment mod­els suc­ceed or fail, and in the case of MIPS, it would ap­pear doc­tors are on board.

The CMS re­ports 91 per­cent of el­i­gi­ble clin­i­cians are par­tic­i­pat­ing in the pro­gram. The agency cur­rently is re­view­ing com­ments on pro­posed rule changes that, among other things, would open up the pro­gram to make more doc­tors el­i­gi­ble to par­tic­i­pate in it.

The em­pha­sis on re­sults means pa­tients will start, per­haps slowly and grad­u­ally, hear­ing more from their doc­tors. They’ll get more fre­quent re­minders about vac­ci­na­tions and pre­ven­tive screen­ings such as mam­mo­grams and colono­scopies. They’ll get more in­struc­tion on tak­ing pre­scrip­tions and re­minders for re­fills, as well as more em­pha­sis on healthy life­style changes.

Pri­vate in­sur­ers have been us­ing value-based pay­ment sys­tems in se­lect plans for years now, Si­dorov said, and now that Medi­care is push­ing the mat­ter, pa­tients are likely to see more fresh ideas come out of the pri­vate sec­tor.

“The thing about the com­mer­cial in­sur­ers is that in their re­la­tion­ships with physi­cians, un­like medi­care, it’s not one-size-fit­sall,” he said. “There are op­por­tu­ni­ties within that re­la­tion­ship for the physi­cian com­mu­nity to work with the in­sur­ers to fur­ther re­fine how those mea­sures are done and the dol­lars at­tached to them.”

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