HHS, CMS, RVUs, APMs, & Burnout

Edward Winslow edbjwinslow at GMAIL.COM
Thu Aug 25 17:14:02 UTC 2016

Fascinating questions:
The answer to the last is the easiest. Yes, traditional FFS model is what
is usually used. In this each service is paid for. The RVU is what everyone
bases payment on. As many know, RVUs are biased in favor of procedures, not
cognitive services. Proceduralists and surgeons are paid more than bedside
clinicians. In addition, physicians are most often paid, by hospitals based
on RVUs, so physicians are incented to generate RVUs. This often leads to
shorter visits in order to generate more RVUs.

In my opinion, burnout is in part related to having to generate RVUs as
well as physicians believing that others are now determining their ability
to generate incomes that they used to be able to do. Up until 1987
physicians set their own fees. Fees were frozen in 1987 as part of the OBRA
of 1987. RVUs came into being in 1989 with the OBRA of 1989 (PL 101-239).
Before that, however, a company known as Ingenix published a series of
opinions on Usual, Customary and Reasonable (UCR) fees that insurers often
based payment on. This began to create a significant friction between
physicians, their patients and insurers  which has continued to this date.

CMS/HHS is trying to get away from FFS, which incents physicians and health
care systems to "do more", without necessarily doing "better". Better is,
however, in the eye of the beholder.

Another cause of burnout may be related to the perception by physicians
that they are being second guessed frequently by litigators who have a
vested interest in finding errors and punishing the perpetrator rather than
having errors corrected by appropriate education.

In that burnout is likely multi-factorial it is unlikely that any single
initiative will be a Magic Bullet that will reverse all of it.

Hope this helps

On Tue, Aug 23, 2016 at 5:19 PM, HM Epstein <hmepstein at gmail.com> wrote:

> I need some expert help, here. If you comment, please let me know if you
> are willing to be quoted or if you prefer to just help out with "deep
> background". I won't quote anyone until I've contacted you personally to
> ensure you are okay with it. I respect the open dialogue here and don't
> wish to constrain it in any way.
> I'm working on an article about the causal relationship between physician
> burnout, and Dx and safety errors. There's plenty of data connecting the
> two. We also have seen lots of studies explaining why physician burnout is
> occurring at a faster rate. Reimbursement via RVUs has been blamed as one
> of the key reasons. [BTW, I highly recommend Anne Lippin's blog posts on physician
> burnout
> <http://annelippin.com/blog/2016/08/08/laying-down-my-stethoscope/> and stories
> from the front lines
> <http://annelippin.com/blog/2016/08/22/the-apollo-mission/>.]
> What I don't fully understand are two elements:
>    1. Do you think that the changes in how Medicare practitioners will be
>    reimbursed will help reduce burnout by changing the focus from number of
>    patients seen to quality of care? Will the change in bookkeeping change how
>    PCPs, hospitalists, intensivists and emergency dept. physicians are
>    evaluated? And how are those changes being judged by the CMS and do you
>    think the criteria will work?
>    2. In March, HHS announced
>    <http://www.hhs.gov/about/news/2016/03/03/hhs-reaches-goal-tying-30-percent-medicare-payments-quality-ahead-schedule.html>
>    they have achieved their goals of tying 30 percent of Medicare payments to
>    quality ahead of schedule. I assumed that they were trying to reduce the
>    number of organizations reimbursed through RVUs (relative value units) but
>    in reading the original January 2015 announcement
>    <http://www.hhs.gov/about/news/2015/01/26/better-smarter-healthier-in-historic-announcement-hhs-sets-clear-goals-and-timeline-for-shifting-medicare-reimbursements-from-volume-to-value.html>,
>    they said "HHS has set a goal of tying 30 percent of *traditional, or
>    fee-for-service*, Medicare payments to quality or value through
>    alternative payment models, such as Accountable Care Organizations (ACOs)
>    or bundled payment arrangements by the end of 2016, and tying 50 percent of
>    payments to these models by the end of 2018.  HHS also set a goal of tying
>    85 percent of *all traditional Medicare payments* to quality or value
>    by 2016 and 90 percent by 2018 through programs such as the Hospital Value
>    Based Purchasing and the Hospital Readmissions Reduction Programs."
>    So, is HHS calling the RVU reimbursement model "traditional" Medicare
>    payments? Or is this program focused on the old fee-for-service model that
>    preceded the RVU model?
> Thank you in advance for your thoughts and comments.
> Best,
> Helene
> hmepstein.com
> @hmepstein <https://twitter.com/hmepstein>
> Mobile: 914-522-2116
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*Edward B, J. Winslow, MD, MBA*
Home 847 256-2475; Mobile 847 508-1442
edbjwinslow at gmail.com

"The only thing new in the world is the history that you don't know"
       Harry S. Truman, 33rd President of US (1945-1953)

"... it can be argued that underinvestment in assessing the past is likely
lead to faulty estimates and erroneous prescriptions for future action."
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine

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