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DECAPITATION
Mary G. Barry, MD
Louisville Medicine Editor
[email protected]
M
y immediate response to the “value
based payments” from Medicare
is, value for whom? To whom?
And at whose cost will all this value take
place?
Capitation in the 90s meant you had a
little financial pie with which to take care
of your patients. If you cut more pieces than
the funds provided, you lost money – no
matter that your patients might have needed
just those exact pieces to prosper. The people who dreamed up capitation had fantasies
of large family doctor practices where the
healthy 22-and-unders outnumbered the
ailing 80-year-olds (truly a fantasy even
today). Internists have a preponderance of
people who are aging and who have multiple things wrong with them at 60, and
acquire more as they get older. The pie tends
to shrink rapidly. Fee for service, according
to all pundits, “rewards volume not quality.” Individual doctors who try to maintain
highly competent care have for many years
been insulted by this widespread belief.
Value based payment began this year
and involves numerous factors. Reading
the official CMS document (CY2015 Value
Modified Policies) brings instant visions of
swelling government payrolls (please note,
various Presidential candidates who rail
against government spending). Very complex calculations and data manipulation are
necessary to arrive at the Value Based Modifier, which takes into account how much
your care of people cost, in relation to how
good your care is, as judged by various czars
of quality. The cost attributable to you for
care for Medicare patients with diabetes,
coronary artery disease, COPD, and congestive heart failure is summed up (in three
pages of various methods and cross-checking of methods). One’s data from the Physician Quality Reporting System or PQRS is
also compared to the cost. Medicare grades
my competence by how thoroughly my eligible patients received every required lab,
medication, test, and referral to specialist
as mandated by the National Committee on
Quality Assurance. Medicare also grades my
competence by the number of admissions
and readmissions, by whether my diabetics
end up losing a leg, whether my patients
with COPD get admitted for an acute exacerbation, etc. Patients are not graded for
their contribution, or lack of same, to these
events. Doctors are thus incentivized to ever
more vigilant nagging, nagging, nagging.
Severity of disease indices also apply, so
at least Medicare has given up the all-people-are-healthy fantasy. “Higher risk beneficiaries” are defined by their Hierarchical
Condition Category score (the word “hierarchical” always makes me reach for my
coat-of-arms, to see what is Herald on a
Field of Old Mutuel Tickets, for instance).
Luckily, in our ongoing battles with bureaucracy, the ICD-10 coding system beginning
next month provides ample opportunity
to make our patients sound precisely sick,
instead of just sick. I must not say a patient
has depression; I must say “Major Depression Single Episode Not In Remission and
Without Psychotic Behavior.” A simple
wrist fracture would now be called “Fracture of the Right Radius, Closed, Without
Malunion and Without Delayed Healing.”
See there? Doesn’t that just make the word
“value” jump right off the page?
Over and over in describing the calculations, the authors of this document repeat
“We will assign a weight to this cost domain” and “We will align this cost domain”
and “We will also take into account patient
safety, population/community health” and
four other realms of “Who is incurring what
cost in whom.” Then they will make some
giant cost composite score and then some
giant value comparison score - assuring us
that national benchmarks apply