Richard Young, MD Sandra Burge, PhD Jason Hill, MS Bryan Bayles, PhD

1. Developing a Fairer Primary Care Payment System: Perspectives of Family PhysiciansAn RRNeT Qualitative Study Richard Young, MD Sandra Burge, PhD Jason Hill, MS Bryan Bayles, PhD

2. RRNeT Infrastructure RRNeT Residency Research Network of Texas

3. Acknowledgements Terrell Benold, Austin Swati Avashia, Austin Sarah Holder, Dallas Raji Nair, Garland Darryl White, Harlingen Sundand Kallumadana, McAllen Tamara Armstrong, SATX-Santa Rosa David Edwards, Lubbock Jerry Kizerian, Corpus Christi Sandra Burge, UTHSC-San Antonio Aktosh Kumar, UTHSC-San Antonio

4. Background • Reams of data from prior observational studies show that having more family physicians in an area delivers better population health at a lower cost. • Barbara Starfield, MD and others

5. Background • Primary care physicians comprise only about 30% of the U.S. physician workforce. • About 50% in other developed countries • Income discrepancy between primary and specialty care explains some of the difference in U.S. physician workforce • Big effect on medical students’ career choices (but not only effect).

6. Background

7. Background • Center for Medicare and Medicaid Services (CMS) published rules on physician documentation, coding, and billing in 1995 and 1997. • Ostensibly to reduce fraud and abuse • Rules not tested or piloted before or after implementation.

8. Background • Rules universally criticized by physicians for being overly complex and onerous. • In 2002, an Advisory Committee on Regulatory Reform of the U.S. Health and Human Services Department reviewed these guidelines and voted 20-1 to eliminate the payment rules. • An advisor for HHS Secretary Tommy Thompson concluded, “documentation guidelines are the poster child for regulatory burden.”

9. Background • But neither HHS or CMS wrote new rules. • Current rule examples • I won’t cover all the complexities. It would take way too long.

10. Background • 89 pages long

11. Background • Primary decision table • New patient requires 3 of 3 to be met or exceeded. • Established patient requires 2 of 3.

12. Background • Secondary decision tables

13. Background – Risk Table • Tertiary table - Don’t try to read this

14. Background – Risk Table From CMS rules: The highest level of risk in any one category (presenting problem(s), diagnostic procedure(s), or management options) determines the overall risk.

15. Background – Risk Table From CMS rules: The highest level of risk in any one category (presenting problem(s), diagnostic procedure(s), or management options) determines the overall risk.

16. Background – Risk Table

17. Background • Other literature estimates that 20-50% of primary care physician’s time during the workday is not paid under the current CMS rules. • Some aspects of PCMH models trying to rectify this. • Care management fees.

18. Research Question • What suggestions do family physicians have to improve the existing CMS documentation/coding/billing guidelines? • What other suggestions about primary care payment do they have?

19. Methods • Interviewed 31 family physicians across Texas • Chosen for maximal variation of themes • Rural • Suburban • Urban • Academic • Private practice • Convenience sample within overall goals at each location

20. Methods • Tell us stories • Sought narrative stories to illustrate ways that the existing CMS documentation/coding/billing rules are not fair to family physicians. • We also sought contradictory cases—for example, services family physicians provide that are overpaid. • What rules should be preserved?

21. Methods • Question development • Spradley method of ethnographic interviewing • Developed a series of ‘grand tour’ questions and successive follow-up probes designed to elicit discussion of specific issues and examples.

22. Methods • Subjects were interviewed by six medical students who were trained in San Antonio prior to launch. • Two to six interviews per student • Interviews transcribed and shared with investigators.

23. Methods - Analysis • Investigators independently used an editing approach to the narratives with the intention of reducing and reassembling the information • Multiple iterations between four investigators. • Still in progress.

24. Methods - Analysis • Felt that not all themes were uncovered in first round. • Students didn’t dig into vague answers enough. • So me and a research assistant from San Antonio interviewed seven more subjects.

25. Results – Subject Demographics

26. Results - Analysis • Five domains emerged • Work poorly paid or not at all • Work fairly paid (or overpaid) • Documentation regulations • Suggested solutions • Role of incentives • Two layers • Concrete • Abstract, underlying root causes

27. Results • Work poorly paid • Multiple issues in one visit or patient “When I look at a patient with multiple problems, after the first or second problem, whenever I address something extra, it’s not being captured and I’m not being paid for that or my clinic isn’t being paid for that.”

28. Results • In contrast: “I wish I were a specialist. It’s the same thing over and over. You do one specific thing: burger and fries, burger and fries, burger and fries. They have it easy and they get paid more.”

29. Results • Work poorly paid • Work that’s not face-too-face “I had a patient … that I spent 20 to 30 minutes just reviewing medication lists outside of the office visit. The patient had been in the hospital, he’s on about 20 different medications from about five different physicians, and the medication list from the hospital did not correlate with my medication list.” (Talks about phone calls and record reviews)

30. Results • Work poorly paid • Coordinating care “Coordination of care is really trying to have a comprehensive picture of the patient and that means reviewing everything that comes in on that patient: labs, radiology reports, reports from home health agencies, from hospital visits, and from specialty visits.”

31. Results • Coordinating care • Review outside information • Test results • Specialist notes • Hospital records • Home health reports • Pharmacies • Reconcile medications • Insurance coverage issues

32. Results • Coordinating care • Contact other parts of healthcare system • Physicians • Home health/hospice agencies • DME companies • Filling out forms • Managing chronic prescription refills • Insurance coverage issues • Patients: e-mails and phone calls

33. Results • Pay discrepancy between private practices and other clinic management structures. • $60 private practice • $120-150 FQHC • $180 hospital-owned clinic

34. Results • Work poorly paid • Complex work in office “[A patient] was having neck pain and some arthritis and she had some shoulder issues; but some of the explanation she got from the specialist didn’t go well. The gave her very brief descriptions of things and she had a lot of concerns and there was a lot of anxiety. …

35. Continued • “I spent a lot of my time just going through what the other people should have done already, and then I spent a lot of time trying to calm the anxiety and just the worries that she had about some of the diagnoses. You are not getting paid for any of that and that is not something you can code. You may do a prime thing, but on paper, it just looks like a follow up on neck pain and arthritis.”

36. Results • Work fairly paid • Procedures • Preventive codes (technically not E/M codes) • Well child exams • Well woman exams • A few insurance companies don’t pay for preventive and acute at the same visit.

37. Results • Documentation • A few subjects said the current system works fine and needs no changes. • Most said rules are too onerous: ex. don’t like bullet counting • “… [M]ost onerous is counting out official [ROS] bullets, two to nine, which is not connected to any reality of clinical practice.”

38. Results • Current system too complicated • Fear of audits • Leads to known under-coding • Took years to learn • Need certified biller/coder to fully capture revenue. • Results in lack of consistency and clarity of interpretation of existing rules.

39. Results “I asked a question [to a national coding conference expert], ‘How would you bill the typical child coming in with otitis media?’ And one person said, ‘Probably a level 2 visit,’ and the other person said, ‘You could go all the way up to maybe a level 4 depending on, you know, what it looked like?’”

40. Results • Incentives • Many statements about proper alignment of incentives • Overuse of procedures by specialists • Overuse of system by patients • Abuse by insurance companies and Medicare • Ways to structure primary care incentives to minimize gaming the system

41. Results • Solutions • Mostly mirrored problems • Coding too complicated  simplify system • Billing not similar across facilities  make consistent • Little support for monthly fees or salaries • Easy work, small fee • Hard work, larger fee

42. Results • Abstract findings • Almost no family physicians understand the CMS rules to a great depth of detail. • Some use cheat sheets • Rules make no intuitive sense • Therefore, they apply the rules by heuristics and patterns. • Err on the side of under-coding to avoid fraud accusations and resultant fines and penalties.

43. Results • Abstract • Most respondents do not think about the aspects of running a business very much. • A substantial minority of subjects had almost no thoughts or concerns about how their patient encounter billings affect their income. • More of these in academic jobs. • Many had no reform proposals on the tip of their tongue. • Resigned to live with existing rules

44. Results • Abstract • Some subjects couldn’t disentangle CMS rules from EMR functions. • “My EMR handles all that.” • Current system encourages fraud committed from physician work-arounds • Pre-filled out templates • Deviate from ideal care because of time burden of existing documentation rules

45. Results • Abstract • Existing rules do not incentivize or improve the quality of care. • Respondents felt extra documentation requirements are just busy work that are not clinically meaningful.

46. Results • Abstract • Existing rules (and maybe other factors) cause family physicians to offer fewer services than they are trained to provide. • Which generates • Unnecessary referrals • Unnecessary tests • Unnecessary trips to the ER

47. Results • Abstract • Existing coding rules do not allow family physicians to tell computers – and therefore payers – the types and quantity of work they do to care for their patients.

48. Limitations • Limited to Texas • More academics than general population of family physicians • Though all saw patients in a personal private practice • Other primary care fields not studied. • No quantification of magnitude of problems.

49. Conclusions • Existing CMS E/M system does not work well for primary care because it does not allow family physicians to express the complexity of work they do and get paid for that work. • We now have a collection of identified problems and proposed solutions that can inform payment reform efforts.

50. Thanks!!