Pay for Performance: The future is on its way!

[Dr. Evil]

You may not know this, but medicare is planning to change the reimbursement rules for dialysis soon.  Soon, docs will somehow have to report a series of outcome measures (ie: labs, percentages, etc) about various outcomes....and their payment will be modified based on whatever they decide is important.

Do you think this is a good idea?

(I have my opinion....but I am just curious to see what yours is first....)

[Sara]

Does this mean the better the outcome for the patient (labs are good, etc.) the more the provider is paid?  If so, on the one hand it might be good because the provider is more motivated to keep their patients healthier, but on the other hand I can see providers dropping certain patients if they are not making them look good.

If that's not what you mean, then sorry I have no idea. 

[livecam]

I don't think a dialysis patient can be dropped for financial reasons.  If it does mean more money for better results then it is a good idea.  It is kind of a catch 22 thing for the operators because there is only so much they can do.  Noncompliant patients will continue to exist as will people with secondary medical conditions and so on.  In the end I think Medicare wants to end up paying less overall and that is probably what will happen.

[Sara]

I'm pretty sure they can say that a patient is being non-compliant and not see them anymore.

[bioya]

we first heard about it in 2004. I think its a good thing. It will force the dialysis provider to do much more to keep the patients healthy. The docs are not involved as the providers as its the providers that titrate your epo, iron, and so forth based on a protocol. All the MD does is approve the protocol. They will not boot out patients that are difficult to maintain a good "report card" on. That would cause a huge legal issue.
All in all, this is a good thing but will cause a lot of bullshitting on your outcomes. I can see the large providers like FMC and DaVita "bending and twisting" data to reflect better outcomes. You know, eliminate this one or that one for whatever reason. I know if some of our outcomes were low we were required to dose up and repeat labs before the end of the month so the improved labs were recorded for the months and averaged in.
Its all a numbers game. But all in all, I think its best for the patient. Just watch out for the exclusions on data.

[livecam]

You sure about that?  We had some major cases of no shows and intermittant shows who were never kicked out.  The unit went through the "patient contract" thing with them to no avail. Think about it, if a unit kicks them out it is tantamount to killing them if there is not another option...but I'm getting off topic here.

[bioya]

I'm pretty sure they can say that a patient is being non-compliant and not see them anymore.

Sara, noncompliance and bad labs are two different things. Yes, noncompliance can and does result in bad labs, but not all the time. A company will not risk legal action dropping patients whose labs are bad. I just don't see that happening. But hey, I have been wrong in the past.

[Dr. Evil]

I am impressed at the brisk responses here.

I didn't anticipate the grouping of the dialysis centers and the docs.
They are two separate groups....the question was aimed at the docs.

The centers staff usually are already paid this way (Usually, the nursing director has bonus, etc. that are tied to anemia outcomes, etc.)

Currently, the docs have no performance measures attacted to their paymenet from medicare or private payors.
[Exception may be the medical director's fee, but this is not tied to any specific patient measure, just the unit as a whole]

[Zach]

You may not know this, but medicare is planning to change the reimbursement rules for dialysis soon.  Soon, docs will somehow have to report a series of outcome measures (ie: labs, percentages, etc) about various outcomes....and their payment will be modified based on whatever they decide is important.

Do you think this is a good idea?

(I have my opinion....but I am just curious to see what yours is first....)

This may be a very good idea.   

Dr. Evil, you really need to give us patients a little more background and information on this topic.
Will these new rules cause the Nephrologists to take back the driver's seat of the Dialysis Unit?

Have too many docs in the past abdicated their responsibilities and let the "consultants and unit administrators" make decisions that affected the quality of care?     

Maybe with a financial incentive those docs will find the courage of their convictions.
And maybe we'll see more doctors making rounds more often.     

[Black]

You may not know this, but medicare is planning to change the reimbursement rules for dialysis soon.  Soon, docs will somehow have to report a series of outcome measures (ie: labs, percentages, etc) about various outcomes....and their payment will be modified based on whatever they decide is important.

Do you think this is a good idea?

(I have my opinion....but I am just curious to see what yours is first....)

Hey Doc, Glad to see ya'!

In theory I think it's really good idea -- reward the Docs who take an interest in their patients, and really try to make them do as well as possible.

BUT, in practice it would probably become a  competitive battle for the "best" patients, who would make the Doc look good -- and rich.

The patients with more serious or uncontrollable problems, and the non-compliant, would be hard pressed to get into a good medical practice and probably wind up with the Docs who don't care and are willing to settle for the minimum payment and have more time to golf.

BTW, did you ever read the presentation on anemia we discussed on the other thread?

Lorelle

[Zach]

BUT, in practice it would probably become a  competitive battle for the "best" patients, who would make the Doc look good -- and rich.

Part of the plan, unfortunately, the good 'ol Dr. Evil fails to mention:

In 2000, the Benefits Improvement and Protection Act (BIPA, Sec 422 of PL 106-554) directed the Secretary of HHS to include a method of "case mix adjustment" to adjust for treatment of higher cost patients.

Dialysis facilities are already reporting hemoglobin and dialysis adequacy (URR) on the bills submitted to their fiscal intermediaries. There are proposals to withhold a percentage of facility and physician reimbursement.  This hold back would create a national pool that could be redistributed according to performance against national standards for dialysis adequacy, hemoglobin management, and fistula placement.


The above comes from Hemodialysis Horizons--Reimbursement for Hemodialysis @  aami.org

There has got to be accountability.  The U.S. mortality rate of dialysis patients is too high.

[Rerun]

I don't blame Medicare for wanting to pay less.  Hell, as a Tax Payer I agree!  If Tax Payers knew how much was spent on dialysis and for some people who don't even know they are receiving treatment??    Iraq is nothing!   

On one hand the Docs need to be held accountable.

On the other hand I don't want them in my business any more than they already are.   

My Dr. doesn't come around all month and then the last week comes twice$$  That is crap!

[Hawkeye]

I'm pretty sure they can say that a patient is being non-compliant and not see them anymore.

You sure about that?  We had some major cases of no shows and intermittant shows who were never kicked out.  The unit went through the "patient contract" thing with them to no avail. Think about it, if a unit kicks them out it is tantamount to killing them if there is not another option...but I'm getting off topic here.

Sara is correct, non-compliant patients can be dropped.  First the clinic tries to find another clinic to transfer them to, but if that doesn't work and the patient continues their bad habits the clinic can say bye-bye.  It is then the responsibility of the patient to find another place to get treatment.  I have never seen it get to this point and I don't really see the clinics having the heart to do it, but it could happen.  If nothing else the will have to go to the Emergency Room for treatment.

[Dr. Evil]

Wow....boy did I open a can of worms.....

Not sure where to start.....

1) Ya'll seem to have some really crappy docs. I don't think anyone has expressed any feelings that their doc works hard for them.  [I am not defending anyone, maybe your docs don't do much for you].  This website is also not fully representative for ESRD pts....I would venture many patients do not have the sophistication to get on a computer, find this site, and use it on a regular basis....many don't even have a computer...So maybe those people do like thier docs better....just a thought.

2) There seems to be a belief that nephrolgists are very wealthy.  Two points: a) Not true, and b) why would this be bad if it were true [ok....this is for another thread]
3) It seems that many believe that most docs just want to get more money.  .....there is a lot more to say here...but does anyone here have a doc they like and they think does a good job?!?
4) Why should docs be punished for poor outcomes when there is no data that we can do any intervention that changes a particular patient's outcome in all every case.
5) Yes- there is some kinda of formula(s) that will be used to 'adjust' for illness level of the paitient......I don't have a lot of faith that it will work well.  [I suppose one could have more faith in medicare.....]
6) Some have picked up on this....I think there will be cherry picking of patients....


gotta run....will write more later

[livecam]

The private nephs who are co-owners of my old dialysis unit are wealthy but then they are co-owners of 3 units and have multi-office practices.  Personally, I liked the way they did business.

I have physicians of the HMO type that I absolutely love.  They will do what it takes to address an issue and when there is an undefined problem will dig deeply with tests etc. until the problem is found.  I have other HMO physicians that I despise because they are obviously addressing the bottom line rather than my needs.  I minimize my interaction with these guys seeing them as infrequently as possible.

[Zach]

1) Ya'll seem to have some really crappy docs. I don't think anyone has expressed any feelings that their doc works hard for them.  [I am not defending anyone, maybe your docs don't do much for you].

I have had two Nephrologists during the past 24 years, (the 1st from 1982-1992 & the 2nd from 1992-current) and both have been hard working medical advocates.

2) There seems to be a belief that Nephrologists are very wealthy.  Two points: a) Not true, and b) why would this be bad if it were true [ok....this is for another thread]

The issue is has nothing to do wealth or lack of ... the issue is quality of care.


3) It seems that many believe that most docs just want to get more money.  .....there is a lot more to say here...but does anyone here have a doc they like and they think does a good job?!?


Again, making a good salary is not the issue, but providing a level of care to patients is the issue.


4) Why should docs be punished for poor outcomes when there is no data that we can do any intervention that changes a particular patient's outcome in all every case.

Maybe not in every case, but perhaps more could be done to improve patient outcomes with what is already known (such as exercise) as well as some innovative thinking on the part of their Nephrologist.


5) Yes- there is some kinda of formula(s) that will be used to 'adjust' for illness level of the patient......I don't have a lot of faith that it will work well.  [I suppose one could have more faith in medicare.....]

If it doesn't work well, adjustments in the policy can be made.  Sometimes I have more faith in Medicare than I do for the Renal Physicians Association and the National Renal Administrators Association.


6) Some have picked up on this....I think there will be cherry picking of patients....

Let's see if this is true. Sounds a bit like a scare tactic.

Now I have a question that has been mentioned on this thread:  Can the dialysis unit refuse to treat a patient or is it the physician who can refuse to follow a particular patient, and thus the patient can't dialyze at a unit where no doctor will follow that patient?

[Hawkeye]

Now I have a question that has been mentioned on this thread:  Can the dialysis unit refuse to treat a patient or is it the physician who can refuse to follow a particular patient, and thus the patient can't dialyze at a unit where no doctor will follow that patient?

From what I understand your answer is yes.  Both are true in a way.  Using Fresenius as an example, if a clinic transfers a patient and they go to another Fresenius clinic the nephrologist still needs to see them at that other clinic.  It may not be their normal nephrologist, but one from that clinic or one that covers for that nephrologist at the original clinic.  Our Nephs cover a few different Fresenius clinics I think.  If they go to a clinic outside Fresenius they need to find a new Neph.  As far as Nephs are concerned, just like your regular doctor can say they no longer wish to treat you a Neph can say the same thing.  Unfortunately I'm sure it happens more often than you may think.

[Dr. Evil]

Now I have a question that has been mentioned on this thread:  Can the dialysis unit refuse to treat a patient or is it the physician who can refuse to follow a particular patient, and thus the patient can't dialyze at a unit where no doctor will follow that patient?

I am not sure about the "must" part, but usually a doc has to accept the patient AND the dialysis unit has to accept the patient.  For example...I may take care of a medicaid patient and accept that I will not get paid (as I do not accept medicaid)..."ie- write it off."  If I then want to dialyze that patient, the local unit will not take the patient as our local unit doesn't take medicaid (..or has a quota of one or two medicaid patients and if no spots or open...they won't take them).  So I am stuck and my patient will have to dialyze at the local hospital as it is a county hospital and they can't say no. 

Also, I may follow a patient who has been discharged for bad behaviour at clinic A, but clinic B will not accept the patient due to their history.  A dialysis unit has no obligation to dialyze anyone that they feel is a risk to the unit, financial or otherwise.

As a doc, you can also discharge from your practice anyone you want.  If you have hospital privileges, part of that usually is ER call.  In that case, you cannot refuse a patient who you are asked to see when you are on ER call, regardless of ability to pay.  Once they leave the hospital, you then do not have to follow them.  As always, you are at risk for medical liability for anyone you see or have a professional contact with.

It is hard just to throw the patient out of a unit for (what I call) benign non-compliance (like not taking your binders, forgetting some paperwork, etc).  If a unit discharged someone without a good DOCUMENTED reason, then the ESRD Networks can get involved and start a medicare investigation (or state investigation), and that is messy and unit directors don't really want that.  So you really have to threaten people or do something more malignant to get thrown out of a unit, and usually it has to be repeated after you are warned, etc, etc....

The last point is that I believe a physician has to accept a patient before the dialysis unit can accept them for dialysis (Medicare compliance issue, as the unit cannot bill unless a physician who has privileges at that unit signs the actual prescription for dialysis, even on a transient basis).




EDITED:   Fixed Quote - Goofynina/Moderator

[Zach]

Hey Dr. Evil,

Thank you.   

You're a good man.

[Dr. Evil]

Hey Dr. Evil,

Thank you.   

You're a good man.

Thanks

[MelissaJean]

I agree with some of the posts here that there are too many factors out of a doctor's control.  Sometimes I feel my performance is out of my control... but I am still a new patient.

And to answer your questions Dr. Evil.  I absolutely loved my Nephrologist at Stanford, he was amazing!  However I just can't make that 2 hour drive more than once a month.    I also met a new doctor ( my first PD doctor) who I was impressed with.

The reason I think Nephrologists are wealthy:  The two months that I was doing hemo, my doctor came around once.  We talked for about 10 minutes, mostly him asking me about my lung transplant, etc.  He didn't really consult me about anything, and I got the bill... $500. I should have been charging him!

Would it be bad if they got paid that much?  No, not if they spent time with me, and did a consultation that would help a new dialysis patient understand what is going on.

[hemohortensia]

I agree with Zach that this may be a very good idea.

However, mortality and morbidity rates have to be adjusted to the health of the patient population.

Some doctors have more elderly patients and patients with multiple illnesses. Clearly, performance should be
matched against physicians with like patient populations.

Non-compliance has to be carefully documented as well.

I believe there are two types of patient non-compliance.

One is what I call "informed non-compliance".

Our unit briefly tried the Althin dialyser. I felt so lousy, I terminated my treatment an hour early. I agreed to try it once more and felt so ill, I demanded to cut my treatment immediately and insisted on my blood being thrown out rather than returned.  My non-compliance paid off - but not for the 50+ patients who died because the dialyzer was defective.

My other "non-compliant" acts include refusing Propulsid, Halcion, and Vioxx, two of which I believe were taken off the market.

[Epoman]

Wow....boy did I open a can of worms.....

Not sure where to start.....

1) Ya'll seem to have some really crappy docs. I don't think anyone has expressed any feelings that their doc works hard for them.  [I am not defending anyone, maybe your docs don't do much for you].  This website is also not fully representative for ESRD pts....I would venture many patients do not have the sophistication to get on a computer, find this site, and use it on a regular basis....many don't even have a computer...So maybe those people do like thier docs better....just a thought.

2) There seems to be a belief that nephrolgists are very wealthy.  Two points: a) Not true, and b) why would this be bad if it were true [ok....this is for another thread]
3) It seems that many believe that most docs just want to get more money.  .....there is a lot more to say here...but does anyone here have a doc they like and they think does a good job?!?
4) Why should docs be punished for poor outcomes when there is no data that we can do any intervention that changes a particular patient's outcome in all every case.
5) Yes- there is some kinda of formula(s) that will be used to 'adjust' for illness level of the paitient......I don't have a lot of faith that it will work well.  [I suppose one could have more faith in medicare.....]
6) Some have picked up on this....I think there will be cherry picking of patients....


gotta run....will write more later

Sorry Doc, just now saw this thread, let me reply to your questions in numerical order:

1) Yes you are correct about the representation part, many patients are just to old to care to go on the computer and find help or learn more. We do have a few members who think their doctors are wonderful. You just have not read all the posts.

2) LOL, come on you know that's not true, what is your definition of wealthy? I know for a fact that my previous neph was wealthy. But to me it doesn't matter if a neph is rich, I think thats a good thing, a person works hard goes to school, then to med school, then into a specialty, they deserve to be rich. I just don't like the nephs that have "sooooo" many patients they can only spend 1 minute of time, once or twice a month discussing issues with them.

3) I have met some good nephs and I have met some AWFUL nephs. There are members here who love their nephs.

4) They should be held accountable and if a patient dies because of non-compliance then fine the doctors off the hook, HOWEVER if a doctor missed something in a lab result and ignored it or forgot to do something to investigate it more fully because he had to many patients to handle then yes he should be held accountable.

[Mom3]

Once again this has me wondering about what happened to my son and if this new ruling could have something similar happening to other pts. My son was losing wt and the clinic and dr's were not adjusting his dry wt resulting in a horrendous fluid overload over time. (Labs were great on paper, yet anyone with eyes could see something was gravely wrong!) Doctors were very reluctant to hospitalize him (had to force the issue by taking him to a hospital ER in another system who recognized the emergency immediately and sent him to his home hospital where the nephrologists had to follow him.)

I have long wondered if they deliberately kept that paper work looking good for their own purposes even though they were literally killing him... Guess you might say my trust is not what it might be anymore...

Makes me wonder if having good paperwork could be more important than having healthy pts...?

Mom 3

[MiSSis]

You may not know this, but medicare is planning to change the reimbursement rules for dialysis soon.  Soon, docs will somehow have to report a series of outcome measures (ie: labs, percentages, etc) about various outcomes....and their payment will be modified based on whatever they decide is important.

Do you think this is a good idea?

(I have my opinion....but I am just curious to see what yours is first....)

I don't think this is off-topic but if it is, I apologize.  In talking about Medicare changing the reimbursement values for dialysis, I'm assuming you mean doctors will get greater return if they can show good results for their patients.  In my case, I currently get better than average levels when my center has us do our quarterly adequacy testing.  (I'm a PD patient.)  I am anally compliant which my docs love and get consistently good results on my monthly blood tests also.  Will Medicare insist I decrease the amount dialysis I'm doing in order to bring me more in line with their recommended levels?  Aren't there currently certain levels of hematocrit and hemoglobin beyond which they won't pay for EPO or Aranesp injections?  While I believe in holding people accountable for their actions (and this works in any aspect of life, not just medicine), I get a little nervous thinking about my care being dictated by Medicare and it's potential reimbursement policies.