The latest focus of the payer community is Quality of Care. The form of providing Quality services is taking shape in the form of Pay for Performance. Although most payers will acknowledge that there is a lack of accurate data to actually pay physicians for appropriate quality care, the market is forcing private payers and Medicare to include some Pay for Performance incentives in their current offerings. The primary push for these programs is coming from larger employers buying insurance and health care for large numbers of employees.
Although these large purchasers of health care are moderately concerned about the health of their workforce, the primary driver is once again money. Lost work days from poor choices in health care are one economic concern but are clearly secondary to the concern for the costs of funding health insurance for their work force. To this end it appears that large employers are focusing on containing costs from two angles:
1) Personal behavior and choices leading to increased health care costs.
2) Physician recommendations and decisions to treat health care.
To address the first item Health care plans and companies are increasing informational flow to patients for both disease prevention and treatment. They are also placing more responsibility for care on the patient from a monetary standpoint in the form of higher deductibles for treatment and lower deductibles for prevention, as well as higher patient responsibility for insurance premiums for patients that are not “healthy” through life style choices. It is hard to fault the goals of these choices.
The second item requires action by the physician community. Without adequate data and physician participation the decisions on how to treat patients will be made under direct payment pressure from the payer. If allowed to continue unchecked the physician will simply be a technician providing a menu of services determined most cost effective by a third party. Payment for services under the insurance company paradigm does not take into account long term patient care as most patients will change insurance companies several times during their lives. The typical tenure with a given insurance company is 5 years or less. Couple this with corporate profit motives and decisions for patient care in the private sector will be focused on cost savings during a 5 year period.
Physicians around the country are already feeling the influence of pay for performance and although Urology is not the first focus, diseases such as incontinence, BPH and prostate cancer are quickly moving up the radar screen.
The decisions on health care choice will be based on data. Collective long term data controlled by physicians offers the best hope for true quality of care and cost efficiency. As such it is time for Urologists to begin the data collection efforts that will at the very least give them a seat at the table in the future of Health care economics.
As you know Medicare has a slightly different outlook on care then the private payers do. Medicare beneficiaries do not leave Medicare. They may change within Medicare but the payment responsibility remains in Medicare. As such Medicare has taken a slightly different approach to market pressures surrounding quality of care. Below is brief description of the latest Medicare plan to become a proactive purchaser of quality health care, published in The Urology Times for June 2007.
Regardless of which payer is making the change, it is up the physician community to take control of the health care system once again. This new market shift provides an opportunity to make that move or let the payer control Health care once and for all.
Medicare:
(Taken from Urology Times article for June 2007)
The Physician Quality Reporting Initiative (PQRI) is a program established at the end of last year to provide incentive funding for physicians to begin submitting data that will be used to make Medicare a smarter purchaser of Health care. The PQRI program will run from July 1, 1007 through December 31, 2007. Physicians can participate if they submit bills to Medicare and have a provider number (NPI), there is no sign up or enrollment process.
The incentive for participating in the program is a 1.5% bonus for each physician meeting certain participation levels. The bonus will be calculated on the aggregate approved allowed amount for all claims submitted by each qualified provider during the data collection period. The approved allowed amount is the amount to paid by Medicare and the recipient including deductible and co-payments for services provided to Medicare beneficiaries. The bonus is subject to a cap established by a formula we have yet to figure out and will be paid in a lump sum in 2008. To be eligible for the bonus you must submit the required coding on at least 80% of 3 measures selected by the office that are applicable to your patients.
Currently there are 74 measures for which Medicare has provided reporting specifications. We have identified 12 measures which may apply to Urologists, however each practice will need to determine the most appropriate measures to use. The length of this article will not permit full listing of the 12 measures and will instead analyze on measure. (For all measures and related information, review the information posted on the CMS web site www.cms.hhs.gov/PQRI) The twelve measures identified for Urology include measures 20-23, 30, 37, 41, 42, 46, 49 and 50 and address issues related to peri-operative care, osteoperosis and incontinence.
Each measure identifies circumstances that require additional reporting by ICD-9 and/or CPT codes (denominator). The required CPT category II codes or G codes that are to be reported on claims for these patients with a charge of $0.00 (or $0.01 if your system will not process $0.00 charge claims) are listed in the measure (numerator). In addition there are 4 modifiers that can be appended to the category II codes or G codes describing circumstances that caused the patient to not receive the measure. Each measure description will also identify the allowed modifier for the measure.
All of this may sound a bit foreign so we will break down Measure # 23 briefly. Note: only codes from the Genitourinary and Male Genital section of CPT are included here.
For all patients receiving a service from the following list:
50020, 50220, 50225, 50230, 50234, 50236, 50240, 50320, 50340, 50360, 50365, 50370, 50380, 50543, 50545, 50546, 50547, 50548, 50715, 50722, 50725, 50727, 50728, 50760, 50770, 50780, 50782, 50783, 50785, 50800, 50810, 50815, 50820, 50947, 50948, 51550, 51555, 51565, 51570, 51575, 51580, 51585, 51590, 51595-51597, 51800, 51820, 51900, 51920, 51952, 51960, 55810, 55812, 55815, 55821, 55831, 55840, 55842, 55845, 55866
Report CPT category II Code 4044F: Documentation that an order was given for venous thromboembolism (VTE) prophylaxis to be given within 24 hours prior to incision time or 24 hours after surgery end time with a charge of $0.00.
If the VTE was not ordered you will append modifier 1P (not ordered/given for Medical reasons documented in the chart) or 8P (not ordered/given for unspecified reason) to code 4044F to indicate the circumstance documented as the reason the VTE was not ordered or given.
The instructions for this are relatively easy to understand. Implementation will take some planning and execution for each office. We continue to evaluate multiple strategies to effectively include PQRI in your office. It may be easiest to develop a charge sheet add-on including these codes so that the physician can communicate the measure codes for each patient qualifying. We hope to have a few suggested forms posted on the auacodingtoday.com website in June. Further we are interested in other suggestions you may have to handle this additional reporting requirement.
