CMS Innovation Advisor Project Representing Group 4

1. CMS Innovation Advisor ProjectRepresenting Group 4 Richard Young, MD Director of Research John Peter Smith Hospital FMRP Fort Worth, Texas ryoung01@jpshealth.org

2. Group 4 – The Island of Misfit Toys

3. My Project - Background • People from the middle of the country, especially medium and small communities quickly understood my project. • People from large cities, particularly the Washington DC to Boston corridor did not understand my project.

4. Three Problems • National shortage of primary care physicians • Onerous primary care documentation, coding, and billing rules • Patients with the most chronic diseases cost the most to care for

5. Why Worry? – Primary Care Texas

6. Ologist Supply - Quality

7. Ologist Supply - Cost

8. Family Physicians - Quality

9. Family Physicians - Cost

10. Another Model: WeCare • Example from a manufacturing facility in Indiana • 1,100 employees 2,300 lives • One-year savings: $4 million • Net clinic costs

11. Summary – Better Quality and Lower Costs • It’s an issue of physician supply • But little interest in adult ambulatory primary care among U.S. medical students • 8% family medicine • 2% general internal medicine (if that)

12. Why the Lack of Student Interest?

13. Second Problem • Onerous Evaluation and Management (E/M) documentation, coding, and billing rules. • HCFA created these rules in 1995 then 1997 • Reason? -- Fraud and Abuse • No vetting, validating, piloting

14. E/M Rules • In 2002, an Advisory Committee on Regulatory Reform of the U.S. Health and Human Services Department reviewed these guidelines • An advisor for HHS Secretary Tommy Thompson concluded, “documentation guidelines are the poster child for regulatory burden.” • Voted 20-1 to eliminate the payment rules.

15. CMS E/M Rules – Example From the Risk Table:

16. The CMS Document 89 pages!!

17. And There’s More Another 100 Pages

18. Third Problem –Chronic Disease Costs

19. My Project - Assumptions • Interest in primary care among medical students will not increase until the income disparity is fixed. • Existing CMS documentation, coding, and billing rules are the primary cause of the income disparity.

20. My Project -- Assumptions • Better U.S. primary care supply to take care of everyone, especially patients with multiple chronic diseases, leads to: • Better health • Better patient experience • Lower costs

21. What is My Project? • To throw away the existing CMS E/M documentation, coding, and billing guidelines and start all over.

22. Driver Diagram Medical Students $ Adult Primary Care Ologies

23. More Assumptions • The solution is NOT to pay family physicians $200 for a sore throat. • The solution is to pay family physicians for all the work they do that currently isn’t paid for. • Literature: 20%-50% of work NOT paid • Align incentives to achieve better efficiencies and outcomes.

24. My Previous Research • Family physician cost-effectiveness • Article to be published in Family Medicine this spring. • Family physician opinions of current system • Manuscripts in progress

25. Project Development • Formed advisory/feedback team • 23 family physicians • Survey - Listed 28 units of work not currently explicitly paid under current system • Vote for: • Paid as a separate fee • Paid as a global fee • Just part of our job

26. More Supporting Work • Surveyed doctors in other countries about their documentation, coding, and billing rules. • U.S. is the only country that ties documentation to payment

27. Solution - Principles • If the physician can’t tell a computer what he or she did, then he or she won’t get credit for the work. • New system – Clinic work is additive • One issue = small bill • Many issues = big bill • Incentivize primary care to provide as comprehensive care as possible.

28. Solution - Principles • Incentives • No incentive to order tests • No incentive to order treatments • Both of these incentives exist in the current system.

29. My System Innovations – Documentation • Chronic diseases • Effect on Quality of Life • Effect on Functionality • Adherence and Tolerance to Medications • Pertinent Physical Examination • Pertinent Lab/X-ray results • Maximal Medical State (Treatment Goal) • Treatment Plan

30. New System – Coding • Issues Addressed code -- IA.x • Becomes primary code • Replaces existing CPT codes (99213, etc.) • 3 Levels • 3, 2, 1 • Level billed is a function of Thoroughness and primary care Responsibility

31. New System – New Codes and Fees(a few examples) • Work Requiring Extra Time • Example: Advance Directive Discussions • Global Fees (care coordination) • Different approach • Non-Face-to-Face Work • Emails, phone calls, text messages

32. Discourage ExcessiveUtilization - Professionalism • Few Examples: • Clear statement that one of the goals of primary care is to be a good steward of medical resources • Use generic medications whenever possible • Spread out visits for patients with stable chronic diseases

33. Validation of This System • I observed family physicians in private practices • I recorded • Times • Number of Issues Addressed • Which issues addressed • Procedures, referrals, expensive tests ordered, labs, X-rays, etc.

34. Typical Practice • Avg. visit length 17.5 min. • Avg. # issues/visit 3.5 • Issues Addressed • Thorough 0.8 • Moderate 1.8 • Brief0.9 • Avg. # Tests and RXs 1.6 1.0 • Avg. Fee Collected$99 • Avg. New System Fee $117

35. Typical Practice • Declined patient requests for services • $3 declined services for each $1 of revenue • Some unnecessary services • About $1 unnecessary services for $1 revenue • My system includes incentives to lower this amount

36. Validity - # Issues • Good agreement between me and observed physician for number of issues addressed in each visit Complete Agreement R2 = 0.66, P< .001

37. Validity – New Fee vs. # of Issues Addressed R2 = 0.77, P<.001

38. Examples – Quick Visit

39. Example: Longer Visit * Existing CMS fees

40. Comparison to Multi-Doctor Approach * Assumes no facility fees

41. Modeling of New Approach: Effect on Physician Income • Income under existing rules/fees • $169,000 • Income under my new approach, no change in practice style • $245,000 • Income assuming FP is a little more thorough • $283,000

42. Effect on Physician Income • Income assuming more thorough plus capture more non-face-to-face fees (emails, phone calls, etc.) • $326,000 • Income assuming above plus other incentives to provide full basket of services and not overtest or overtreat. • $417,000

43. Run Chart

44. Finally • Lessons Learned • Colleagues for life: Others looking for answers with passion and commitment • I know more about change management and process improvement

45. Barriers • Total Cost Data • CMS: ResDAC data help • My local intermediary disappearing (Trailblazer) • Funding for experiment • Myself • JPS Health Network • Still might happen • CMS • No luck with regional office so far

46. Next Steps • Another cycle of observations to further validate payment model. • Present model to AAFP • CMS – Could start using this system now!!

47. Finally • Thank you Fran • Thank you mentors • Thank you fellow Innovation Advisors

48. Goodbye from the Island of Misfit Toys