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CMS Innovation Advisor Project Representing Group 4. Richard Young, MD Director of Research John Peter Smith Hospital FMRP Fort Worth, Texas [email protected] Group 4 – The Island of Misfit Toys. My Project - Background.

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Cms innovation advisor project representing group 4

CMS Innovation Advisor ProjectRepresenting Group 4

Richard Young, MD

Director of Research

John Peter Smith Hospital FMRP

Fort Worth, Texas

[email protected]

Group 4 the island of misfit toys
Group 4 – The Island of Misfit Toys

My project background
My Project - Background

  • People from the middle of the country, especially medium and small communities quickly understood my project.

  • People from large cities, particularly the Washington DC to Boston corridor did not understand my project.

Three problems
Three Problems

  • National shortage of primary care physicians

  • Onerous primary care documentation, coding, and billing rules

  • Patients with the most chronic diseases cost the most to care for

Ologist supply quality
Ologist Supply - Quality

Ologist supply cost
Ologist Supply - Cost

Another model wecare
Another Model: WeCare

  • Example from a manufacturing facility in Indiana

  • 1,100 employees 2,300 lives

  • One-year savings: $4 million

    • Net clinic costs

Summary better quality and lower costs
Summary – Better Quality and Lower Costs

  • It’s an issue of physician supply

  • But little interest in adult ambulatory primary care among U.S. medical students

    • 8% family medicine

    • 2% general internal medicine (if that)

Why the lack of student interest
Why the Lack of Student Interest?

Second problem
Second Problem

  • Onerous Evaluation and Management (E/M) documentation, coding, and billing rules.

  • HCFA created these rules in 1995 then 1997

  • Reason? -- Fraud and Abuse

  • No vetting, validating, piloting

E m rules
E/M Rules

  • In 2002, an Advisory Committee on Regulatory Reform of the U.S. Health and Human Services Department reviewed these guidelines

  • An advisor for HHS Secretary Tommy Thompson concluded, “documentation guidelines are the poster child for regulatory burden.”

  • Voted 20-1 to eliminate the payment rules.

  • Cms e m rules example
    CMS E/M Rules – Example

    From the Risk Table:

    The cms document
    The CMS Document

    89 pages!!

    And there s more
    And There’s More

    Another 100 Pages

    Third problem chronic disease costs
    Third Problem –Chronic Disease Costs

    My project assumptions
    My Project - Assumptions

    • Interest in primary care among medical students will not increase until the income disparity is fixed.

    • Existing CMS documentation, coding, and billing rules are the primary cause of the income disparity.

    My project assumptions1
    My Project -- Assumptions

    • Better U.S. primary care supply to take care of everyone, especially patients with multiple chronic diseases, leads to:

      • Better health

      • Better patient experience

      • Lower costs

    What is my project
    What is My Project?

    • To throw away the existing CMS E/M documentation, coding, and billing guidelines and start all over.

    Driver diagram
    Driver Diagram

    Medical Students


    Adult Primary Care


    More assumptions
    More Assumptions

    • The solution is NOT to pay family physicians $200 for a sore throat.

    • The solution is to pay family physicians for all the work they do that currently isn’t paid for.

      • Literature: 20%-50% of work NOT paid

    • Align incentives to achieve better efficiencies and outcomes.

    My previous research
    My Previous Research

    • Family physician cost-effectiveness

      • Article to be published in Family Medicine this spring.

    • Family physician opinions of current system

      • Manuscripts in progress

    Project development
    Project Development

    • Formed advisory/feedback team

      • 23 family physicians

    • Survey - Listed 28 units of work not currently explicitly paid under current system

    • Vote for:

      • Paid as a separate fee

      • Paid as a global fee

      • Just part of our job

    More supporting work
    More Supporting Work

    • Surveyed doctors in other countries about their documentation, coding, and billing rules.

      • U.S. is the only country that ties documentation to payment

    Solution principles
    Solution - Principles

    • If the physician can’t tell a computer what he or she did, then he or she won’t get credit for the work.

    • New system – Clinic work is additive

      • One issue = small bill

      • Many issues = big bill

    • Incentivize primary care to provide as comprehensive care as possible.

    Solution principles1
    Solution - Principles

    • Incentives

      • No incentive to order tests

      • No incentive to order treatments

    • Both of these incentives exist in the current system.

    My system innovations documentation
    My System Innovations – Documentation

    • Chronic diseases

      • Effect on Quality of Life

      • Effect on Functionality

      • Adherence and Tolerance to Medications

      • Pertinent Physical Examination

      • Pertinent Lab/X-ray results

      • Maximal Medical State (Treatment Goal)

      • Treatment Plan

    New system coding
    New System – Coding

    • Issues Addressed code -- IA.x

    • Becomes primary code

      • Replaces existing CPT codes (99213, etc.)

    • 3 Levels

      • 3, 2, 1

      • Level billed is a function of Thoroughness and primary care Responsibility

    New system new codes and fees a few examples
    New System – New Codes and Fees(a few examples)

    • Work Requiring Extra Time

      • Example: Advance Directive Discussions

    • Global Fees (care coordination)

      • Different approach

    • Non-Face-to-Face Work

      • Emails, phone calls, text messages

    Discourage excessive utilization professionalism
    Discourage ExcessiveUtilization - Professionalism

    • Few Examples:

      • Clear statement that one of the goals of primary care is to be a good steward of medical resources

      • Use generic medications whenever possible

      • Spread out visits for patients with stable chronic diseases

    Validation of this system
    Validation of This System

    • I observed family physicians in private practices

    • I recorded

      • Times

      • Number of Issues Addressed

      • Which issues addressed

      • Procedures, referrals, expensive tests ordered, labs, X-rays, etc.

    Typical practice
    Typical Practice

    • Avg. visit length 17.5 min.

    • Avg. # issues/visit 3.5

    • Issues Addressed

      • Thorough 0.8

      • Moderate 1.8

      • Brief0.9

    • Avg. # Tests and RXs 1.6 1.0

    • Avg. Fee Collected$99

    • Avg. New System Fee $117

    Typical practice1
    Typical Practice

    • Declined patient requests for services

      • $3 declined services for each $1 of revenue

    • Some unnecessary services

      • About $1 unnecessary services for $1 revenue

      • My system includes incentives to lower this amount

    Validity issues
    Validity - # Issues

    • Good agreement between me and observed physician for number of issues addressed in each visit

    Complete Agreement

    R2 = 0.66, P< .001

    Validity new fee vs of issues addressed
    Validity – New Fee vs. # of Issues Addressed

    R2 = 0.77, P<.001

    Example longer visit
    Example: Longer Visit

    * Existing CMS fees

    Comparison to multi doctor approach
    Comparison to Multi-Doctor Approach

    * Assumes no facility fees

    Modeling of new approach effect on physician income
    Modeling of New Approach: Effect on Physician Income

    • Income under existing rules/fees

      • $169,000

    • Income under my new approach, no change in practice style

      • $245,000

    • Income assuming FP is a little more thorough

      • $283,000

    Effect on physician income
    Effect on Physician Income

    • Income assuming more thorough plus capture more non-face-to-face fees (emails, phone calls, etc.)

      • $326,000

    • Income assuming above plus other incentives to provide full basket of services and not overtest or overtreat.

      • $417,000


    • Lessons Learned

      • Colleagues for life: Others looking for answers with passion and commitment

      • I know more about change management and process improvement


    • Total Cost Data

      • CMS: ResDAC data help

      • My local intermediary disappearing (Trailblazer)

    • Funding for experiment

      • Myself

      • JPS Health Network

        • Still might happen

      • CMS

        • No luck with regional office so far

    Next steps
    Next Steps

    • Another cycle of observations to further validate payment model.

    • Present model to AAFP

    • CMS – Could start using this system now!!


    • Thank you Fran

    • Thank you mentors

    • Thank you fellow Innovation Advisors

    Goodbye from the island of misfit toys
    Goodbye from the Island of Misfit Toys