Hospitals are increasingly putting 5-30% of physician money either “at-risk” or as a bonus based on quality incentive metrics. This change applies both to employed physicians and contracted groups. In my informal surveys, it’s safe to say doctors often hate quality metrics and hate having money tied to them. It’s true that many of them are clinically meaningless or are more related to documentation than practice. However, as CMS increases incentives/penalties based on hospital-based metrics, it’s unlikely this practice will disappear.
The amount of money on the line for physicians can be impressive, and doctors who want to maximize earning power should pay close attention to the development, execution, and analysis of their incentive metrics. There are several common mistakes doctors make related to incentive pay, which means they may be leaving money on the table.
Mistake #1 Giving up Control of Quality Documentation
Not having to click extra boxes is great, isn’t it? Wouldn’t it be awesome if the documentation could just be pulled from billing data or from nursing documentation, and you could just focus on patient care? Of course it would, but then you lose all control of your at-risk quality money. What if the nurses change their workflow and the box they used to check gets forgotten or deleted? What if there’s a new coder who doesn’t understand the difference between a nerve block and a spinal? Suddenly checking that extra box doesn’t seem so bad when it earns your group an extra $50,000.
Mistake #2 Making the Payments Once a Year Rather than Quarterly
Too many hospitals and practices have yearly quality incentive payments. This is great for the hospital since they only have to run the numbers and cut a check once a year. For doctors, though, it’s terrible. With yearly incentive payments, you have no time to correct course during the year if you need to make changes to documentation, clinical practice, or the metrics themselves. Quarterly metrics let you make changes as the year goes on.
Mistake #3 Not Making an Effort to Include Something Meaningful
Sarah Gebauer, MD
Let’s be honest, many of these metrics are either explicit or implicit ways to check documentation, which is one of physicians’ least favorite parts of medicine. It’s already taking as much as 30% longer to document in an EHR, then you have someone looking over your shoulder to make sure you did it perfectly. However, I’m willing to bet you can think of at least one metric that would be helpful for you in your practice. For anesthesiologists, perhaps it’s number of patients with vomiting in PACU. Knowing if I was doing poorly (or well!) would make a difference in my practice, since preventing post-op nausea and vomiting is something I think about daily and incorporate into my plan. It’s tempting to just blow off the whole quality metric thing as a waste of time, but there’s a lot of information in the EHR. Try to make it work for you.
Mistake #4 Choosing Something Exceedingly Rare, and then Putting Zero Percent as a Goal
This is a great way to lose your incentive money. None of your patients would ever have a catheter-related blood-stream infection, right? You do literally everything possible to avoid them and haven’t had one in years. Using that as one of your metrics is practically money in the bank. But then there’s a patient who gets an infection after surgery, and she also has a Hickman catheter, and the very very rare bacteria that grow happens to not be included in the CMS guidelines for exclusion. Even though you argue up and down that clinically it’s clearly a surgical infection rather than a catheter infection, you still get dinged. It will drive you crazy that it’s tied to thousands of dollars and doesn’t make sense clinically. Just don’t do it. Choose more common processes or outcomes that don’t have a zero percent goal.
Mistake #5 Not Developing an Explicit Appeals Process
No matter how diligent you are with developing your metrics, it is likely that you’ll disagree with the results the hospital gives you at least a few times. Should this case count? If there’s a case in which the care was provided but the documentation is not in the usual spot, will the hospital accept an alternative? A common example in anesthesiology is pre-op antibiotic administration. If the drug was pulled for the patient in the Pyxis and the nurse documented it was given as part of the time-out, but the anesthesiologist forgot to click the antibiotic box in the EHR, will the hospital accept the Pyxis and nurse documentation as an alternative? Obviously, you can’t anticipate every alternative documentation possibility, but the ability to submit additional documentation to support that a metric goal was reached is important — and can get you thousands of extra dollars. Having a good relationship with your hospital administration is very helpful in this process as well.
In summary, being engaged with your quality incentive payments can help you earn more money for the hard work you already do.
What do you think? What mistakes have you made with incentive payments? What have you done to maximize incentive pay? How much of your income is based on “quality” related metrics? What do you think about the current ways quality is measured and incentivized? Comment below!
This is an interesting topic, and has been front and center for sometime now. It has gained tremendous momentum ever since the advent of the Physician Quality Reporting System (PQRS). In those “good ‘ol days,” we simply submitted our data to CMS via a registry based system. We knew it would be heading in the current direction, but did not know how it would turn out.
The private medical groups, hospital systems, ACO’s, and End Stage Renal Disease Seamless Care Organizations (ESCOs) are monitored for their outcomes based on claims based data now. Hence, these organizations pass on the love to their physicians. If the physician meets her metric, the organization can meet their metric, and in theory the incentives are aligned. Some of the incentives are appropriate and simple, for example the flu vaccine and depression screening. Some incentives are not achievable so others don’t even try—for example the treating depression metric. I asked the acting director of CMMI in November if he thought fee for service was going away. And, if the value based, population health, pay for performance method would some day become 100 percent of physician compensation. The crystal ball was cloudy, but the opinion is that over then next 15 years the fee for service will go away.
One example I can provide is that metrics are frequently adjusted for serious comorbidities. The ICD 10 code must be accurate for a leg amputation. That is because patients with leg amputations are sicker and tend to have worse outcomes from others with no amputation. And, even if it is coded appropriately for 2019, in 2020 if you don’t resubmit the ICD 10 code on at least one claim, the comorbidity does not count for 2020—a quirk of the system is that the comorbidity drops off unless you add it again, so don’t forget.
The only real defense, is to look at the Physician Philosopher’s website and read his motto, or read “The Good Life” chapter again in the WCI original book. Take the pay cut, and earn money on your money. Your bonus will come from being an owner of the outstanding companies in the world and their great performance.
Great post, and interesting business concept that the author has pioneered.
Thanks for the comment. I agree that it’s unlikely these payments are going away. And the very frustrating quirks you mention are just a few of the many that are likely costing some docs thousands of dollars.
I’d say that knowledge is the alternative to taking a pay cut. Most (though not all) of the contract incentives can be improved with good questions, evidence, and clarification during contract negotiations.
That’s an interesting view of the future of physician payments. I’m hopeful that there will be some major improvements in the metrics and quality of the data during that 15 year timeframe, though converting fully to a value-based compensation model would require some significant validation by CMS to be even remotely fair to physicians.
This is an especially important topic for primary care practices. You have to build the infrastructure to collect and submit this data accurately and completely without affecting your ability to deliver good care. This means hiring care managers, social workers, and pharmacists, and having partners willing to engage and serve on committees to ensure proper implementation. Using NPs and PAs to do those 7-day hospital follow ups and home visits also helps. Incentive payments represent 20 to 30% of adult primary care practice compensation and I don’t see this decreasing in the future. If it is managed well, I think these programs benefit both physician and patient. It does, however require substantial investment (both time and money) on the front end.
Thanks for bringing this up. I completely agree that accurate data collection is absolutely crucial – and expensive. The yearly change in metrics can make this especially difficult, since you may have to re-train multiple employees and partners about new data collection each year. Knowing in which area in the EHR the data needs to be entered can have a huge impact on the viability of a practice.
One nice feature where I work is they do these QM bonuses on a monthly basis, so I can course correct easily. They top out at 10% of base pay so the last 2 months of the year there are small/no bonuses if I did exceedingly well the first 10 months.
Some of these incentives are considered a shared risk. My group is running in to an incentive/hold back on metrics.
As a fellow anesthesiologist, you’ve probably encountered the standard metric of “on time starts”. I have no control over sterile processing not having trays ready, patients showing up late, and one thousand other items that conspire to make in room time after 7:30.
I want to play the game; but I want to choose a metric that ensures I win!