HHS, CMS, RVUs, APMs, & Burnout

Tom Benzoni benzonit at GMAIL.COM
Thu Aug 25 20:13:45 UTC 2016


This may inform the discussion:
http://www.pnas.org/content/107/38/16489.full.pdf
I figure all are familiar with Kahneman's work.
No reason to think docs are a special exception.

External validity would agree; docs will take a poorer paying job they find
more fulfilling.

tom benzoni

On Thu, Aug 25, 2016 at 12:14 PM, Edward Winslow <edbjwinslow at gmail.com>
wrote:

> Helene,
> 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
> Ted
>
> 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
> winslowmedical.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
> to
> lead to faulty estimates and erroneous prescriptions for future action."
>         Eli Ginzberg, 1997
>
>
>
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> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
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>
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