Quality-based payment is coming; are you ready?

February 1, 2009

Data, data, data. It's the key discussion point in almost any article about health care reform.

You have read about the waste in the health care system and the relatively lower quality of care being provided in the United States. Congress, large corporations, and patients are all looking for more for their health care dollar. Insurance companies, Medicare, Medicaid, and other programs are reacting to the demand. Medicare is in the process of switching its payment system to a value purchasing system rather than one that passively pays for services.

With all that in mind, the goal of this article is to put into perspective how you, the practicing urologist, should view the data discussion and what you need to do to prepare for the future.

The Physician Quality Reporting Initiative (PQRI) and pay for performance programs are the first attempts to collect and use data. We hear a number of physicians commenting that the programs are unfair, biased, and have nothing to do with evidence-based medicine (EBM). The fact that physicians and even payers agree that the data for true EBM is sorely lacking is not stopping the marketplace reaction.

Why should you be concerned about the discussion about data?

What to do

What can you do about this shift? Here are two options to consider.

Do nothing. Most physicians are already too busy to worry about adding new processes and procedures to start collecting data related to quality. Further data analysis and packaging of data to prove that you are a quality provider will take time away from your patients.

Although we disagree with the bury-your-head-in-the-sand approach, there is an argument for doing nothing. In the next few years, there will be more patients needing care than providers, and time spent away from providing care is costly and may not greatly improve patient care right now.

Participate. Actively submitting codes to PQRI is a good start. The startup process is relatively easy, and although the program has seen its share of problems, most are having little trouble getting codes submitted to Medicare.

The payment for participating is small but is not the primary reason for playing the game. A good reason to participate is that Medicare represents the best chance to influence treatment guidelines at this time. Finally, if you do not participate, Medicare has shown it is not afraid to act without full data or physician support. Like it or not, quality-based pay is coming.

Of course, participation is a pain and the pay is too low. Many are worried that the data is being developed to use against physicians in the future. Another argument against participation is that a lack of data makes it harder to enact protocols.

If you want to get ready for the future, act now. Although we are late in starting to play the data game, it's not too late. Payers are already judging your quality and the cost efficiency of your care. Other organizations are getting into the act. The best, most complete, and most accurate data will be the data owned and interpreted by physicians.

We have already lost hundreds of thousands of dollars by not knowing the payer rules. We need to act now to stop the hemor-rhaging.

If you wish to work less and make more in the future, the best method is to change the way you market your services. Marketing your practice based on quality and cost-efficient care will be the key to success in the future. Couple this change with the shift to more first dollar out of pocket for patients and the change in patient flow secondary to quality measures developed by payers, and you may have little choice. It is our belief that the quality argument is just beginning. Doing nothing now will cost you later.