[Editor's Note: Our first guest post of 2020 was submitted by Sarah Gebauer, MD. Dr. Gebauer is an anesthesiologist, palliative care physician, physician informaticist, and the founder and CEO of Ilumina Health, helping physicians and hospitals develop trustable data. We have no financial relationship. I decided to run this post because I think it provides some good examples of places where physicians get burned in their contracts, especially when a significant portion of their pay is based on “quality” measures that are anything but. In fact, too many doctors' “quality” is simply a euphemism for reducing physician pay through tricks like those discussed here. Happy New Year from all of us here at WCI!]


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

physician incentive payments

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!