While in medical school, I learned about what was then called GRID (gay-related immune deficiency) and we now know as HIV/AIDS. I thought this condition would become so central to practice in nearly any specialty that I decided to try to keep up with all of the literature on it. It wasn’t yet in textbooks, so I thought it would be very important to keep up with all the new research studies and review articles about it.
I kept in my apartment a growing file of articles photocopied and torn out of journals. But I had badly misjudged the enormity of the task, and within a few years, there were far too many articles for me to read or keep up with in any fashion. Before long, HIV medicine became its own specialty, and while it has always been something I, like any hospitalist, need to know something about, I’ve left it to others to be the real HIV experts.
I was naive to have embarked on the quest. What seemed manageable at first became overwhelming very quickly. The same could be said for trying to keep up with new payment models.
New Professional Fee Reimbursement Models
For decades, most physicians could understand the general concept of how their professional activities generated revenue. But it’s gotten a lot more complicated lately.
The growing prevalence of capitation and other managed-care reimbursement models in the ’80s and ’90s might have been when reimbursement complexity began to increase significantly. But while nearly every doctor in the country heard about managed care, for many, it was something happening elsewhere that never made its way to them.
But for hospitalists, I think the arrival of the Physician Quality Reporting System (PQRS, originally Physician Quality Reporting Initiative, or PQRI) marks the swerve in reimbursement complexity. Some years ago I wrote in these pages about the importance of hospitalists understanding PQRS and described key features of the program.
Like HIV/AIDS medicine literature, the breadth and complexity of reimbursement programs from the Centers for Medicare & Medicaid Services (and other payors) seem to have grown logarithmically since PQRS. The still relatively new bundled payment and MACRA-related models are far more complicated than PQRS. And they change often. Calendar milestones come and go with changes in relevant metrics and performance thresholds, etc. Even the terminology changes frequently. Did you know, for example, that under MIPSi “Advancing Care Information” is essentially a new name for EHR Meaningful Use?
Bundled payments and MACRA are only a small portion of new models implemented over the last few years. There are many others, and dedicated effort is required just to keep track of whether each model influences only physicians (and other providers), only hospitals, or both.
Clinicians’ Responsibility for Keeping Up
My thinking about most hospitalists, or doctors in any specialty, keeping up with all of these models has evolved the same way it did with HIV/AIDS. I think it’s pretty clear that it’s folly to expect most clinicians to know more than the broad outlines of these programs.
Payment models are important. Someone needs to know them in detail, but clinicians should reserve brain cells for clinical knowledge base and focus only on the big picture of payment models. Think how well you’ve done learning and keeping up with CPT coding, observation versus inpatient status determinations, and clinical documentation. You probably still aren’t an expert at these things, so is it wise to set about becoming an expert in new payment models?
Instead, most hospitalists should rely on others to keep up with the precise details of these programs. Most commonly that will mean our employer will appoint or hire one or more people, or engage an outside party, to do this.
Don’t Feel Guilty
It’s common to leave a presentation or doctor’s lounge conversation on payment models feeling like you need to study up on the details of this or that payment model since good performance under that model will be important for your paycheck and to remain a viable “player.” And speakers sometimes intentionally or unintentionally enhance your anxiety about this. Maybe they love to show off what they know, and it’s easy for them to think only about their topic and not keep in mind all of the other stuff you need to know.
It’s terrific if someone in your practice is particularly interested in payment models and chooses to stay on top of them. Just make sure that doesn’t come at the expense of keeping up with changes in clinical practice. Most groups won’t have such a person and should rely on others, including SHM, without feeling the smallest bit of guilt.
SHM is advocating on behalf of hospitalists and working diligently to distill the impact MACRA and its various alternative payment frameworks will have on hospital medicine. With webinars, Q&As, and additional online and print resources, SHM will continue to provide digestible updates for hospitalists and their practices.
The End of Small-Group Physician Practice?
While the intent of these programs is to encourage and reward improvements in clinical practice, keeping up with and managing them is a tax that takes resources away from clinical practice. This is an especially difficult burden for small private practices and may prove to be a significant factor in nearly extinguishing them. There are relatively few small private hospitalist groups,ii but all of them should carefully consider how they will keep up with new reimbursement models.