HHS, CMS, RVUs, APMs, & Burnout

Michael.H.Kanter at KP.ORG Michael.H.Kanter at KP.ORG
Thu Aug 25 20:53:17 UTC 2016


Interesting topic.  So reasons for burnout are complex and I think we need 
to be careful to not attribute it to one reason.  Income insecurity is one 
issue but physicians may burnout from loss of control of their practice, 
personal problems unrelated to work, illnesses like depression, and many 
other factors.  Whether changing the reimbursement model will decrease 
burnout remains to be seen although I can see where it may increase 
burnout and frustration if the quality payments are deemed to be unfair or 
based on poor metrics.   In the system I work in, the physicians are not 
paid based on RVUs but on a base salary plus extra for quality and service 
and access metrics and there is still some burnout.   I recently wrote an 
article about physician satisfaction at work that is a bit different from 
burnout but clearly related and may be of interest.  Generally most 
physicians were reasonably satisfied with their daily work but I would say 
that burnout is still a significant issue.
I believe that medical groups need to proactively attempt to address it or 
quality, safety, service, and diagnostic reliability will drop.

 

 

Michael Kanter, M.D., CPPS
Regional Medical Director of Quality & Clinical Analysis
Southern California Permanente Medical Group
(626) 405-5722 (tie line 8+335)

Executive Vice President,
Chief Quality Officer,
The Permanente Federation

THRIVE By Getting Regular Exercise

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From:   Edward Winslow <edbjwinslow at GMAIL.COM>
To:     IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Date:   08/25/2016 12:52 PM
Subject:        Re: [IMPROVEDX] HHS, CMS, RVUs, APMs, & Burnout



Caution: This email came from outside Kaiser Permanente. Do not open 
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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 and stories from the front lines.] 

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 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, 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
Mobile: 914-522-2116



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