All of this, and more, are roles that are not typical in a traditional medical practice. Undoubtedly, the job descriptions of frontline nursing and office staff will need to be updated. But these kinds of skills may require new talent with a background in data management, IT systems integration and/or performance improvement. While it may not be possible to identify each person accountable for these answers on day one of QPP participation, the answers must be clear before the data is due.
Practice employment agreements must also be updated. No longer is it realistic to have providers compensated solely on relative value unit production. Given the offset between data submission and payment adjustments, there must be elements of provider compensation based on the more interim steps of quality data gathering, quality measure performance, in addition to any value-based program payment adjustments.
In addition, contracting should address concepts around the portability and ownership of physician-related quality data. This will become painfully relevant if a provider changes practices in the middle of a reporting year or is anticipating some sort of value-based payment after a job change. The goal must be to have compensation and work expectations calibrated to reflect the reality of revenue generation for the practice.
FURTHER READING: 2018 payment outlook results
The fact is, completing notes and bills, seeing enough patients per day and/or capturing hospital or nursing home charges may no longer be enough to be successful. There may very well be a point in the near future when a clinician who sees a high volume of patients, but does not capture the correct discrete data consistently, could earn less revenue than a data-oriented and pop-health focused clinician.
Seeing fewer patients, while capturing data conscientiously, dedicating time each week to population health activities and working toward avoiding ED visits and well-coordinated discharges from the hospital may be the new picture of success. Realistically, it will take several years to agree and enact such changes to the typical employment agreements in the typical practice. However, creating a chain of accountability from the exam room to the practice’s quality payments two years later requires such change.
The pace and price of change
Despite all this “good advice,” it may seem idealistic and obvious. The hardest part is the economics of this process. There is no easy way to align the costs of practice transformation with the stream of revenue, at least to the degree to which it is required. Investments in time, and energy often feel like expensive distractions from the day-to-day work of a high-volume, encounter-based practice.
To be sure, there are short-term lost revenue opportunities. The contracts and programs that would yield the financial return on investment for these kinds of changes are still nebulous and new. And yet, to demonstrate even a modicum of success in even the QPP, some minimum threshold of transformation is required. It is difficult to do only a “little bit” of population health.
Participation in QPP/MIPS or a well-managed advanced APM are good first steps. A thoughtful practice walking down either of these paths would be wise to aim for more than just the minimum work for the most immediate financial gains. Rather, understanding and implementing the larger lessons, tactics and strategies can be the initial momentum needed in getting closer to the loftier goals of practice transformation and population health. Ultimately, and irrespective of the short-term economics, the question is: How many of these changes can you afford to ignore?
Adam J. Weinstein, MD, is vice president of medical affairs, clinical IT services for DaVita Kidney Care, a part-time nephrologist in Maryland and chair of the Renal Physicians Association’s Quality Clinical Data Registry workgroup.