You have read about the waste in the health care system and the relatively lower quality of care being provided in the United States. Congress, large corporations, and patients are all looking for more for their health care dollar. Insurance companies, Medicare, Medicaid, and other programs are reacting to the demand. Medicare is in the process of switching its payment system to a value purchasing system rather than one that passively pays for services.
With all that in mind, the goal of this article is to put into perspective how you, the practicing urologist, should view the data discussion and what you need to do to prepare for the future.
Existing data programs
The Physician Quality Reporting Initiative (PQRI) and pay for performance programs are the first attempts to collect and use data. We hear a number of physicians commenting that the programs are unfair, biased, and have nothing to do with evidence-based medicine (EBM). The fact that physicians and even payers agree that the data for true EBM is sorely lacking is not stopping the marketplace reaction.
Why should you be concerned about the discussion about data?
If you have ever gone to Google and entered your name in the search box, chances are, among the top returns will be physician quality rating sites. With a decided lack of true EBM data for most diseases, your practice’s data is compared to guidelines, measures, and your fellow urologists’ practice data. While most agree that this approach is far from where we should be, it is viewed as the best way to determine who should be paid for providing quality care at present.
What can you do about this shift? Here are two options to consider.
Do nothing.
Most physicians are already too busy to worry about adding new processes and procedures to start collecting data related to quality. Further data analysis and packaging of data to prove that you are a quality provider will take time away from your patients.
Although we disagree with the bury-your-head-in-the-sand approach, there is an argument for doing nothing. In the next few years, there will be more patients needing care than providers, and time spent away from providing care is costly and may not greatly improve patient care right now.
Participate.
The startup process is relatively easy, and although the program has seen its share of problems, most are having little trouble getting codes submitted to Medicare.
The payment for participating is small but is not the primary reason for playing the game. A good reason to participate is that Medicare represents the best chance to influence treatment guidelines at this time. Finally, if you do not participate, Medicare has shown it is not afraid to act without full data or physician support. Like it or not, quality-based pay is coming.
Of course, participation is a pain and the pay is too low. Many are worried that the data is being developed to use against physicians in the future. Another argument against participation is that a lack of data makes it harder to enact protocols.
If you want to get ready for the future, act now. Although we are late in starting to play the data game, it’s not too late. Payers are already judging your quality and the cost efficiency of your care. Other organizations are getting into the act. The best, most complete, and most accurate data will be the data owned and interpreted by physicians.
We have already lost hundreds of thousands of dollars by not knowing the payer rules. We need to act now to stop the hemor-rhaging.
If you wish to work less and make more in the future, the best method is to change the way you market your services. Marketing your practice based on quality and cost-efficient care will be the key to success in the future. Couple this change with the shift to more first dollar out of pocket for patients and the change in patient flow secondary to quality measures developed by payers, and you may have little choice. It is our belief that the quality argument is just beginning. Doing nothing now will cost you later.
Get more from data
Start by collecting data on your performance from your practice management data and compare it to that of your colleagues. Request data comparison reports from payers, if they have them, or contribute to a collective database that can be accessed by you without payer control.
Most agree that claims data cannot be used to determine quality of care or even cost-efficient practices. However, claims data is an accurate reflection of activity in the health care system and is the most widely available data set; therefore, claims data is the primary data analyzed for quality and cost-efficient care.
By collecting and following standards, your practice will be able to develop its programs in a non-punitive environment. Additionally, developing and/or following accepted practice standards and/or treatment protocols and notifying payers of your participation may positively affect patient flow and payment from the payer. If you wait for payers to design the program, you may not like what you see.
As you can gather, we feel strongly that physicians need to prepare for the shift to a quality payment market. In other words, lead or follow, but do not simply stand aside.
Physician Reimbursement Systems felt strongly enough about the direction of the marketplace to develop an easy-to-use tool box to allow urologists to add to a national urology data set and access the data to compare your practice to that of your colleagues. The tool, called the Urology Data Initiative, is a web-based data portal that works like a clearinghouse, with no disruption to your current office flow.
We have discussed previously the value of redacted payment tracking data in determining the payment practices for private insurers. Private insurers’ bundling edits only agree with Medicare edits part of the time, and private payers do not publish their edits. The only way we will ever be able to map the precise payment rules and practices is through shared data.
By monitoring claims data in a combined data set, urologists will have the ability to influence the future of health care. This, in turn, will provide the added benefit of bettering their business in today’s difficult market.
Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver and is also publisher of Urology Coding and Reimbursement Sourcebook
Mark Painter is CEO of PRS Urology SC in Denver.
