Learning to make quality pay

Physicians want to deliver quality care to patients, and most want to get off the hamster-wheel life of earnings that are driven solely by volume. But the shift to pay based on quality metrics is a scary new world too. “Physicians are used to being rewarded for someone walking through their door but the people who are buying healthcare today understand that approach is costing our country a lot,” says Jeffrey J. Cain, MD, FAAFP, president of the American Academy of Family Physicians (AAFP).

Cain believes, however, that being paid for results is good news for primary care physicians because they bring a tremendous amount of value to the healthcare system. “(That value) has been under-recognized in the way that we’ve been traditionally been paid in fee-for-service,” he says. The changing approach will affect payments from Medicare and Medicaid, as well as private payers, he says.

Medicare already offers several programs through which physicians can earn bonuses for quality, he says. For example, Meaningful Use (MU) bonuses for effective use of electronic health records (EHRs).

“You can earn $39,000 in the course of 2013 to 2016 if you start participating in 2013,” Cain says. “But if you wait until 2014 to begin participating, then you’ve lost about $15,000 of that. By 2015, they start penalizing you.”

The same thing happens with electronic prescribing, he says. Starting to do it now nets you a .5% bonus from Medicare. But if you are not e-prescribing by next year, you will face a 2% penalty.

Focus on what you are already doing

Between MU, the coming adoption of International Classification of Diseases-10^th Revision (ICD-10), the formation of accountable care organizations and health insurance exchanges, adopting quality metrics can feel like just one more demand being piled on, says Rosemarie Nelson, a practice management consultant with MGMA Health Care Consulting Group and a Medical Economics editorial consultant.

“There is a point where a wall goes up and the physician and practice administrator say ‘Enough.’ Because of that, it is hard to think through each one individual issue separately,” she says. But she stresses that the shift to quality metrics isn’t so bad. Many practices are already pursuing certain quality metrics through MU, and even those that are not attesting to MU may still be reporting through the Physician Quality Reporting System (PQRS). “They can focus on those quality metrics they are already reporting on,” she says.

Stage 2 of Meaningful Use will align with the PQRS, Nelson adds. “It’s a perfect starting block. As physicians actually report on those metrics and manage their behaviors and patient interactions, they can start to reap the benefits because they will learn from themselves how effectively they are working through these quality metrics,” she says.

For example, having alerts that pop up when a patient with diabetes hasn’t had a foot exam is something many practices are already doing. “But now you are going to get ‘extra credit’ or avoid a penalty for this,” she says.

Look for opportunities for take on the basics, she advises, such as heart disease or diabetes, as a way to encompass many of the early quality efforts. MU has 38 quality metrics, she says. Pursue the ones that are pertinent to your patient base. “Even things as basic as making sure all the kids are immunized are quality metrics you can use. Build those alerts into your system and monitor them,” Nelson advises.

Getting started

Teresa Koening, MD, MBA, senior vice president and head of the clinical integration practice at The Camden Group, a healthcare consulting firm, suggests that physicians eyeing the path of quality metrics start by analyzing their own environment. Take a hard look at your operations, specifically revenue collections, expenses, payer contracts, and involvement in fee-for-quality programs, Koenig says.

“Where are you struggling? What do you want to control? What are your options as we move into this new model of payment?” she says. “Physicians are really smart people but often they are too busy to really evaluate all these different aspects of their office.”

Make sure you are heading toward the new model, she says, and making the most of your market’s opportunities for quality rewards. Also, make sure you have maximized grant money from the government or other sources to get fully functional with an EHR system. “To survive in the new world, you are going to have to be able to transmit electronically and you will have to put your data into some type of health insurance exchange,” she says.

Nelson also recommends that physicians take an objective look at their data. Query your EHR about how well you are doing on some patient subset, such as how many diabetic patients have a certain hemoglobin A1C reading. She thinks that any physicians will be shocked by what they find. “Everyone feels they are doing the best job possible, yet we have practices that don’t measure up,” she says.

Notify your payers

Nelson suggests that once practices have compiled this data, they present their highlights to their largest payers to show how well they are doing. “Everyone complains that payers don’t pay enough,” she says. “Don’t presume that because you are not aware of an incentive plan that it doesn’t exist. It may very well exist. You have to look for where these incentives are.” Often, payers target large physician groups for these initiatives, so small practices need to drive their participation themselves, she adds.

Quality programs

Cain suggests physicians ask themselves a few questions: “Am I participating with Meaningful Use with my EHR? Am I participating in the PQRS program? If I’m in a large group, am I participating in the value-based modifier program? Am I getting ready for ICD-10?”

With PQRS, physicians can get bonuses for participating in 2013 and 2014. Those bonuses become penalties in 2015 and 2016 for not participating, however. “The payments that are received and the penalties are ‘look back’ penalties,” Cain says. “Physicians need to start participating now because otherwise their wallet is going take the hit in the future.”

That’s also true for the value-based payment modifier program, which is for physician groups of 25 or more, he says. Groups that show higher quality and lower cost based on this year’s data will be getting payments in a year or two. “Again, this is challenging because they are ‘look back’ payments. So it is important physicians are active now in understanding if they are qualified to participate in the value based payment modifier program,” he says.

However, some penalties can be removed for practices that start to participate in quality improvement activities in the future, he notes, so it is not just now or never.

Patient adherence

Patient noncompliance is a huge variable in achieving high-quality data, most experts agree. No matter what you do, some patients won’t quit smoking, exercise, or lose weight. Nonetheless, “in the newer healthcare systems, we are going to be responsible for all of our patients,” Cain says.

He notes that some physicians are better at helping their patients quit smoking than others and suggests physicians try to learn from them. “By using active collaboration with our patients and understanding the stages of change and understanding behavioral health approaches, we can be more effective,” Cain says. “It is going to be frustrating to be held responsible for someone else’s behavior but the good news is we will be reimbursed for being more effective at it. We have to be able to ask ourselves how we are doing for making certain patients are taking their medications, coming back for visits, and monitoring their blood pressure and such.”

An example of a problem that can arise, Nelson says, is when patients with diabetes skip regular checkups because they know they have not been following their regimen well and don’t want to get a lecture. Then they get sick with an acute problem such as influenza and have to come in. The patient needs a comprehensive diabetes appointment as well as an acute visit, but the scheduler has only put them in for a 15-minute slot.

“Too many doctors will merely treat the acute problem and ask the patient to return for diabetes follow up care, but the patient won’t do it,” Nelson says. Practices that are committed to quality will say that no matter why that patient came in, we are going to take care of all his or her issues, she adds.

Technology can help facilitate this, she says. For example, have the alert that the patient is overdue for a diabetic visit pop up at the scheduler’s desk, not just the nurse/doctor’s screen. Then the scheduler knows to schedule them for a longer visit. “That is a key operational secret that people don’t get from their vendors,” Nelson says.

Koenig notes that physicians may start getting some help with patient adherence as more employers and health plans are adding rewards for employees for achieving certain health benchmarks, such as lowering their weight or quitting smoking.

Defensive medicine

Koenig encourages physicians to be careful to avoid engaging in defensive medicine as they shift to quality metrics. Follow the care guidelines of your colleges whenever possible, she says, citing a study published in the New England Journal of Medicine that showed physicians only follow guidelines about 55 percent of the time. “Medicine is as much an art as a science, so hitting target guidelines 100% of the time is not appropriate for every patient, but 55% is a bit low,” she says.

When you do deviate from standard guidelines, be sure you understand why, she says. “We are doing too much of the wrong stuff,” she adds.

Living in the gap

Although Cain and the others are optimistic about the future of primary care as quality metrics start to drive payments, they agree it represents a challenge now because most practices are still being paid for volume. “We are smack dab in the middle,” he says. “The analogy I like to use is that it is a bit like you are standing on a dock and there’s a boat that getting ready to leave, and you’ve got one foot on the dock and one foot on the boat. And you have to decide if you are going to stay on the dock or get on the boat. Or are you going to get wet?

“For family doctors, it is important to understand the things that are in motion now. They don’t have a choice of getting on the boat or not for things like PQRS, Meaningful Use, or e-prescribing. It’s important to start to understand the components of the Patient-Centered Medical Home (PCMH) and its ability to improve quality and lower cost,” he says.

Cain says that both public and private payers are seeing the value of encouraging PCMHs. “If insurance companies invest in the medical home, we can decrease the number of unnecessary emergency room visits and hospitalizations,” he says. “The challenge for primary care physicians is that it’s a different kind of caring for folks. It’s not just waiting for a patient walk through your door. It’s reaching out to the patient.”

By taking steps such as having a care manager call patients to see how well they are doing with their care plan, patients will be healthier and will spend less money on their care. And physicians will be rewarded.

He notes that the AAFP’s TransforMED program helps primary care practices become high-performing PCMHs. “As practices move toward a PCMH model, they start better understand their practices,” he says. “Often when a small to mid-size practice adopts the PCMH model, they also improve work flow in ways that help them in their current business model.”

Next steps

Going forward on the quality metrics journey, Koenig advises physicians to get help from resources such as their local medical society. “Don’t spend a lot of money getting help,” she advises. “But do the basics as appropriate for your environment. If there is a hospital or health system you work with, ask if they have any supports you can use. Are there other medical groups in your same situation you can bounce ideas off of?

“Unfortunately, this transformation necessitates that physicians prepare for the new normal while also living in the present,” she says. “As long we can keep it around good patient care and doing the right things, I think we can survive, but it’s not easy. There is no magic wand.”