There’s “A New Game” in Town!

Fifteen years ago, Mark and I started  “preaching the gospel according to Saint Coding”.   

We addressed the coding and reimbursement issue with you prior to its becoming a major bottom line issue. This started with a series of seminars entitled, “There’s a New Game in Town.” We predicted that the payment system was going to become very detailed and complicated. Unfortunately, our predictions not only became reality, but they also progressed beyond our expectations with the intrusions of payers in our practices. Once again we must announce, “there is a new game in town.”

Empowered by incomplete data about your practice, some payers are judging the treatment decisions you make for your patients, and paying or withholding payments based on those judgments. If these payments have not impacted you at this point, they will, unfortunately, in the future. Medicare and private payers plan to include all physicians in all states.

The movement to improve quality and to assure cost efficient care is going to be even more important to your practice in the future than coding and reimbursement has been in the past.

Urologists need to prepare. Urologists must be able to report their practice information in comparison to the AUA guidelines and measures, payer data, the AMA Consortium guidelines and measures, among others. 

PQRI, as discussed by Mark and Jeff in two previous articles, is the beginning of Medicare’s movement in this direction. Medicare has stated that they will not continue to be a “passive payer” for health care services. They are going to become an “active purchaser” of services, which means they are going to monitor pay for quality and cost efficient care and will become more involved in determining what is, or is not, medically necessary. 

How the entire health care reform will play out, nobody knows. With unhappy physicians, patients, and payers, we can say with certainty that the system is unstable and will change. We cannot predict the type of system that will emerge. However, we know some of the changes that will occur. We can expect more controls over services provided and paid, “transparency” of both quality and pricing on all practitioners, more educated patients, and purchasers of health services “with more skin in the game.” In other words, they will be more active and pay a higher percentage of the cost. 

We can hang our hat on the fact that there will be more scrutiny by payers and others on the way we practice. It is projected that a fair percentage of our future income will be paid depending on the way we practice. 

One could envision a system in which approximately two thirds of your income comes from fees for services, and one third comes from bonuses for being a quality, cost efficient physician. The split would be even higher! The exact methodology will remain temporarily unknown, however the direction is clear.

Physicians need to be able to compare their practice to their colleagues to see how they “stack up” and be able to counteract any false accusations or any unverified published data regarding their practice. To accomplish this, one must collect and organize personal data efficiently. We also need to have a collective data set from all urologists for comparison purposes in order to determine the true standard of care. 

In addition, we owe it to our patients to let them know that we are committed to the practice of quality medicine, fair in our pricing, and cost efficient in the services that we order and/or provide. 

Keep in mind your income is not the key target even though this has been the easiest target for the Feds and other insurance companies, because they’ve had the data. As a result, we’ve been forced to go along with their contracts. It is not the $400 they pay you for the surgery, it’s the $12,000 hospital bill and the $1,000 worth of drugs that’s killing the system. 

We need to change that trend. We physicians need to commit to our patients that we are practicing quality medicine and are being cost efficient in what we order/provide. If we’re not, we need to change. Your patient still has faith in you. If we do nothing as a profession, or as an individual physician, then things will erode as they continue to get more and more information “confirming” that we have not been good stewards of the dollar or that we are not doing the right thing at the right time. 

Here are four things you need to do in your practice now in order to be a player in the ‘new game’:

1. Organize your data so that you know how well you are meeting the guidelines and measures put out by the AUA, the AMA Consortium, etc.

2. Join fellow urologists in making a commitment to patients that you are “getting in the game” and practicing quality, cost efficient care.

3. Work to make your practice more efficient in reporting, billing, collecting and seeing patients.

4. Work with the AUA, ACS, and the Urology Data Initiative to collect and utilize data to prove, and or, improve you practice standards. 

With the new game, physicians have the opportunity to recapture the control of the system. If the system is truly interested in quality, cost efficient care, there is only one group that can provide that. That is the medical profession. We urologists are the only ones that can truly define, provide, and monitor quality, cost efficient urology care for our patients.

Join the Urology Data Initiative that will be offered in the near future to share the data, and show your patients that you are committed to the quality, cost efficient process.