Tuesday, September 29, 2009

P4P Quality measure with CPT is not in our future


“The system is broke”, is a far more common phrase we continue to hear. Whether it is a politician eager to promote more support for healthcare reform, or a patient who is too frustrated due to the sheer volume of bills they get from 10 different entities, just to have one procedure for appendix removal. Even physicians who are penalized for using too many CPT codes or procedure count to treat a complex condition and get penalized from the payers for it under their P4P programs are saying it.

So this begs the question, is P4P Quality measures with CPT the right thing? We are seeing that many of these programs have not shown a tremendous adoption from physicians. Take the PQRI initiative, statistics have shown an average of $700.00 return per physician which is relatively low comparing it to the costs the practice has incur. This begs the question, is it worth looking at P4P programs and worrying about implementing them? Is the technology available to measure the outcomes of patient treatment over time?

Is it possible that physicians will be paid based on treatment outcome?

Well, if you review the ARRA and what 2015 will bring you will a clear indication as part of the meaningful Use goals to be“clinical outcome measures, efficiency measures and safety measures”, you will realize that there is a tremendous emphasis on outcome measures this might not mean that you care providers would be required to follow the recommendations, but it will mean that if CMS does make the outcome measure as a mean to reimburse you on patient treatment, then as we know Payers will usually just follow.

What are the current facts?

The good news this possible change would not affect the way physicians provide care. Many care providers do see and treat the patient based on some mental measurements and grading if the patient is or is not improving. But it does get sticky when a group needs to report on it on paper. Take for example a patient being treated for a broken wrist. We can measure the outcome of the treatment based on the level of Pain, we can track the range of movement of the wrist after the cast is done and we can measure the improvement on the amount of time it took to have the cast off. While in many cases the person’s body will dictate some of those results, but we can still benchmark the treatment outcome.

However, when you consider the patients with chronic disease such as End-Stage-Kidney disease then the complexity increases tremendously. During a recent presentation by CTG, they had a very interesting approach to this challenge. They basically created a Master Patient Complexity index that they can use measure the patient condition through well defined scientific measures such as: Age, Hemoglobin, Creatinine, Bun, BMI, Calcium, Potassium and so forth. With a plot as radar spokes as shown here(Values are based on fictitious data and do not represent actual patient information).

Result and the impact of this direction

This can potentially result in a shift of paradigm. Physicians may not be paid on how many procedures done, but the improvement of their patient’s overtime using a proven Master Patient Complexity index. The current recommended model by CTG looks very promising and may as well be a starting point. There have been implementations of similar models by other groups such as Mayo Clinic. This would also mean that EMR/PMS products would need to have a different approach to how payors are billed and properly display the progress or patient treatment outcome of time. It is just another fun day for BI (Business Intelligence) and health analytics.


While physicians continue to focus on providing care to their patients one must remember that doctors do have to be compensated appropriately. Using CPT for a way to measure care quality is definitely not an acceptable method of measuring the improvement on quality care, so considering other approaches is a must, and looking for technology as a tool to facilitate makes more sense than ever. It also means that physicians must become more involved in product and measure development. This will ensure that future EMR products will answer to the providers needs, improved measures to assist patients with complex conditions and create an efficient reimbursement system.

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