What’s In It For Me?
In one of our recent blog posts (‘Should We Incentivize Physicians In CDI’), I outlined my thoughts on incentivizing physicians for the contribution to an organization’s CDI initiative. If you have been in the CDI space for a considerable amount of time, there is no doubt that you have come across the phrase “What’s in it for me?” either directly when talking to a “difficult” physician, or indirectly during communications with colleagues.
Indeed, it is something that many of us try to prepare for and have an answer for ahead of time in the hopes of being able to provide an answer that immediately causes a physician to see the light and win his/her buy-in. Some of the more common answers include an explanation around:
- Accurate hospital reimbursement
- Individual physician and facility quality scores
- Mortality indices
- Observed/expected ratios
- Length of stay metrics
- Pay for performance models
- Value-based healthcare
- Third-party payer “preferred provider” lists
The truth of the matter is that these topics rarely immediately grab the attention of a physician (except for the first bullet point regarding hospital reimbursement that they often view as “What’s in it for the hospital?”), let alone the community doc who has been admitting patients to your facility long before you even knew what CDI was all about. We all hear and know the ramifications of clinical documentation that does not align with true patient severity and in recent years, making the case has indeed become easier.
If that is the case, why do we still struggle with the “What’s in it for me?” question? I am convinced that the answer lies in the fact that physicians have not felt the “dent” in their pockets just yet.
The discordance between hospital prospective payments versus physician fee-for-service models have not only proven to drive up costs in healthcare, they have also been one of the driving forces behind challenging physician-hospital relationships for many years. When a hospital receives a “set fee” for caring for a patient type, it makes sense for the hospital to be acutely aware of how they report severity on the revenue side and how physicians utilize hospital resources on the cost side.
Yes, you will, in many cases have physicians on your staff who are conscious of this fact and, hence, work diligently to align with value-based healthcare practices and principles, but you will also encounter a large number of physicians who achieve fair outcomes for their patients, but at a much higher cost. Collecting data on the “costly” physicians can be tough, since there are usually multiple physicians involved in the care of a given hospitalized patient, making accurate attribution of costs to individual docs very challenging.
Historically, physicians have had no economic incentive to practice efficiently within the hospital. Consider the scenario where a hospital can only bill for an inpatient stay once the discharge summary is completed, versus the physician who gets paid once their own pro fee claim is submitted – discharge summary or not. There’s an alternative scenario where the physician will get paid for rounding on a patient well beyond the expected length of stay for that patient’s reported severity, but the hospital does not get paid and may, in fact, be penalized for it.
Physicians are, for the most part, still billing under a fee-for-service model and are still incentivized for volume. In a recent survey by the recruiting firm Merritt Hawkins, it was noted that 39% of the physician bonuses were either completely or partly based on quality metrics (time period: March 2016 – March 2017, for jobs they were trying to fulfill). This is progress, they say, since only 23% percent of bonuses were structured that way in 2015. Only 21% of the bonus money, on average, in 2016-2017 was based on quality, which is down from 29% the year before. Quality generally accounted for only 4% of total compensation.
I must agree with Travis Singleton, SVP of Merritt Hawkins, when he says that it is not enough and that anything below 10% is not going to change day-to-day behavior. Yes, there are also factors outside the influence of physicians that take up far too much of the “quality bonus” dollars, like patient satisfaction scores and patient non-compliance. MACRA, designed to phase out FFS, is still not well understood by many physicians and has not resulted in the desired change in their behavior, yet.
In another survey, Bain & Company reported that more than 70% of physicians prefer a fee-for-service model, even though they recognize that it is more expensive, as they are not yet convinced that value-based models improve clinical outcomes.
So, this is essentially what we are up against: An environment that still largely incentivizes volume, and a value-based model with a limited impact on the physician’s pocket book, a lack of clarity on the linkage to patient outcomes, and a lack of credible quality score reporting.
Perhaps the best way to answer the “What’s in it for me?” question, and surprisingly, probably not the most effective way, is that it’s the right thing to do.
“Real integrity is doing the right thing, knowing that nobody’s going to know whether you did it or not.”