CMS Innovation Advisor ProjectRepresenting Group 4

Richard Young, MDDirector of ResearchJohn Peter Smith Hospital FMRPFort Worth, Texasryoung01@jpshealth.org

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

OlogiesAdult Primary Care

Medical Students$

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 ExcessiveUtilization - 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 17.5 min. Avg. # issues/visit 3.5 Issues Addressed

– Thorough 0.8– Moderate 1.8– Brief 0.9

Avg. # Tests and RXs 1.6 1.0 Avg. Fee Collected $99 Avg. New System Fee $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

0 1 2 3 4 5 6 7 80

1

2

3

4

5

6

7

# Issues Addressed Count

My Count

Observed Physician's

Count

R2 = 0.66, P< .001

Complete Agreement

Validity – New Fee vs. # of Issues Addressed

$40 $60 $80 $100 $120 $140 $160 $180 $200 $220 $2400

1

2

3

4

5

6

7

8

Number of Issues vs. New Fee

New Fee

# of Issues

R2 = 0.77, P<.001

Examples – Quick Visit

Example: Longer Visit

* Existing CMS fees

Comparison to Multi-Doctor ApproachIssue Doctor CMS Current Fee*Migraines Neurologist $103Hypertension Cardiologist $69High Cholesterol Lipid-ologist $69Foot Pain Podiatrist $158X-Ray Radiologist $52Low Back Pain Orthopedist $69Preventive Care Family

Physician$131

Post-Menopausal Bleeding

Gynecologist $267

TOTAL 8 $918* Assumes no facility fees

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