Tackling the tricky task of dividing quality bonus payments

Editor's Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Lori E. Rousche, MD, a family physician in Souderton, Pennsylvania. She is also the hospice medical director for Grand View Health in Sellersville, Pennsylvania. The views expressed in these blogs are those of their respective contributors and do not represent the views of Medical Economics or UBM Medica.

How do doctors divide compensation that comes into a medical practice in bulk? Who deserves how much money when that money is paid based on quality, citizenship, emergency room visits, timely hospital follow-up appointments, utilization and access to care? Does the doctor that works night hours get more than the doctor that has no night hours? Does the provider who gave the most flu shots get a bigger share than the one that didn’t? Should the provider who had the most hospitalizations be penalized? Should the doctor whose patient had the most expensive and prolonged chemotherapy trials be dinged?

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These are interesting scenarios that come into play with the current state of healthcare payments, which can be bundled or bonused, big or little, and are often coming in at unpredictable times and in unpredictable amounts and sometimes based on confusing metrics.

Lori Rousche, MD

In our group practice, we have had some serious and at times contentious discussions regarding splitting up money that comes in as a bonus to the group, rather than as a fee-for-service payment. Most recently, the insurance group that we are contracted with paid out two bonuses. One was based on quality metrics, over which providers have some control. The other was based more so on utilization, over which we often have very little control. And when I say this, I am speaking more about expensive cancer treatments and recurrent prolonged hospital stays.

With the advent of CPC+ and the increased outreach to our sickest patients, we certainly hope to decrease our ED visits and recurrent hospital visits. However, if your panel of patients has two active lung cancers and say, a liver transplant, you are out of the bonus money. 

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We have seven offices that each were awarded their quality money as an individual office. None of this money was shared with the other offices, because each office works as its own profit center. As a larger group, we felt it would be fairer to keep the quality bonus within the individual offices where it was divided between partners as the members of that office thought fit.

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Each office uses its own staff differently to try to achieve quality. Some make more phone calls, some rely more on the portal and others send emails to patients to try to get the colon cancer screens and mammograms done. In a few of the offices, the doctors are involved with calling patients, and in other offices, just the staff works on this.

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Regarding utilization money, when that check came in, some offices received over $100,000, while other offices received zero. That is correct. Some offices had enough very sick patients, cancer, heart failure, kidney transplants etc., that they received no money.

Now, as a group, we all feel that our group is made up of caring, competent providers who all strive to give their best. Therefore, as a group, is it OK if one office gets a giant bonus, while another office, through no fault of their own conceivably gets no money? 

We had to take a good hard look at whether we were truly partners. The definition of partner is:  a person who shares or is associated with another in some action or endeavor: sharer: associate. Certainly, that means we are partners in the sense of the word with the other doctors in our own office.

However, are we really partners with those doctors in the other offices who we don’t work with on a daily basis? I say we have to be.

If we are going to survive going forward with the changes in payments from all of our insurers, we must stand as one group all together for the common good of providing quality care. In the next quarter, when the bonus check is dispersed, it could be my office that scores zero on utilization, even though I am doing my best at trying to keep my patients well.

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In the end, we voted to divide the utilization bonus evenly among all of the offices according to full time equivalents because that was the fair thing to do. And it was the right thing to do even though there was some grumbling about it. I believe it strengthens our group and our partnership heading forward into the messy future of medicine.