This is always a sticky subject for providers and practice leaders. How providers practice medicine today in the “Bronze Age of Medicine” is vastly different than how providers practice medicine before the 00’s in the “Golden Age of Medicine.” There was always rule and regulations by CMS. However, it has just been in the last 15 years that the rules and regulations have negatively impacted the providers financially. I remember when I first started my career in practice management providers did reasonably well as long as they had reasonable documentation according to the CMS Guidelines. However, now documentation for the same type of visit today is just about tripled causing more work (some providers would say unnecessary work) to get reimbursed. Before there was PQRS, MU, MU stage 2, MACRA, MIPS, MSSP, APMs, CPC+, it was just the provider following the coding guidelines to get paid. Let’s look at this at financially – When a provider saw a patient in the year 2000 for a cold/strep Medicare paid an average of $96 and commercial insurance paid an average $115. Today 2018 Medicare pays on average $75 and commercial insurance pays on average of $90. This is right at about a 22% reduction of payments in just a short 15+ years. So, can you feel the frustration by providers, more work and paid less! How did this all start you say, well keep on reading?
PQRS was the first in the quality measures that Medicare started in 2006. It was voluntary, and providers were paid a significant incentive to participate and report their quality measures, who wouldn’t want an incentive (bonus per say) for just doing your job! Providers started to document just a bit more to achieve the incentive payments and quality measures. However, most of the time the providers were already documenting these items anyway, so it was not too much of a hardship, and providers were happy.
CMS said let’s have the providers do more documentation for the same visit as above for Meaningful Use Stage 1 to promote the EHR/EMR adoption and data gathering, which started around 2009. This was when provider frustration began to increase. Providers saw they needed the incentives to adapt to an EHR/EMR so they begin to add the additional documentation that CMS now requires to achieve the CMS incentives outcomes which may or may not pertain to the patient’s current situation for the office visit. Documentation time increased, and providers started to see the decrease in provider reimbursements. Increase documentation and Decrease reimbursement, in turn, Increase the provider and healthcare leader’s frustration level. Let us remember providers were transitioning from paper charts which was how medicine was practiced during the “Golden Age.” The electronic format which is in our current “Bronze Age.” Imagine the majority of the providers were not computer savvy which added even more frustration on the providers and healthcare leaders. The documentation time went from 1-2 minutes per patient to close 8-10 minutes per patient, which was a major operational issue! Over the last few years the documentation as reduced to 3-5 minutes but still no like it was when the provider documented on paper.
In 2012, Meaningful Use stage 2 came into effect which was the start of the coordination and exchange of patient information stage. This was the stage that added even more documentation and reporting requirement and the penalty clause (insert sarcasm here). As a healthcare practice leader, this was like adding the last straw to the camel’s back. Providers were just about to come apart, they are now, documenting 3 times more, getting paid less, and the added possibility of a penalty of 2-4% reduction to their Medicare payments. Remember in the early 2000’s providers were still getting paid average of $96 by Medicare and $115 by Commercial Insurance plus incentives. By 2012 the average Medicare payment is about $85 and Commercial Insurance $100, and the provider may or may not receive an incentive, but now is REQUIRED to participate in the Quality Measure programs.
In 2016 CMS announces the MACRA (MIPS, APMs) Quality Rules and Regulations. This was to do away with the Meaningful Use and other measures. However, that is not the case as of yet. Now, practice leaders and providers need a (CEHRT) Certified EHR Technology, not just any EHR will do but one that has been Certified by the CMS. Oh, this is a big deal since this means Upgrades or changes in EHR, no additional incentives by Medicare to help with the cost of this process. The reporting period is now 12 months instead of a 3-month period, and the MIPs is not just about Quality, it is now Quality, Cost, Improvement Activities, and Advancing Care Information. The good news however in 2018 Medicare said that it would only require 12 months of data for Quality and Cost and 3-month data for Improvement Activities and Advancing Care. And they would decrease the penalty for PQRS reporting, yay (sarcasm here)! The MACRA (MIPs AMps) is a revenue neutral program which means you will have winners (incentives) and losers (penalty) you must have losers to paying penalties so those payments can go to the winners (incentives). Everyone will be competing for the incentives, and only a few will win those coveted incentives.
In the end, the frustration level just keeps rising for providers and healthcare leaders, because they need those incentives since reimbursements are declining. If by chance the provider or practice is unlucky in reporting and they don’t get the incentives then it is a double whammy declined reimbursement plus a 4-8% penalty (reduction in reimbursement).
Can you feel their pain yet, declining reimbursements, possible penalties on the reimbursements, documentation time increases, more technology costs to keep up all so they can do what their passion which is practice medicine to the sick! In the “Golden Age of medicine” providers made money, not only did they get to practice medicine but they got paid good doing it. Now in the “Bronze Age of medicine,” providers get to practice medicine, but it is not so lucrative. For the providers who, lived in the “Golden Age of medicine” and now is living in the “Bronze Age of medicine” their frustration seems to rise at every turn when changes need to be done to meet these new CMS rules and Regulations!
So what can we do to reduce the frustration level for our providers? First and foremost just Listen, let the provider voice their frustration. Second, look at your operations ask yourself what opportunities are there to help reduce the frustration level. Third, get involved and get your providers engaged in voicing your frustration to the AMA and CMS. Unfortunately, until our providers and healthcare leaders start to stand up and say enough is enough and get involved in the changes taking place at CMS, then these types of rules and regulations will continue. If we continue to see the additional strain on our providers increase, we will start to see providers stop accepting Medicare and Medicaid. We will begin to see more and more providers going to a cash base system or concierge system, and our patients who are covered under Medicare and Medicaid will have less access to providers. That would be devastating to our Medicare and Medicaid patients.
Cissy Mangrum, MBA, CMPE, CPC
Revitalize Healthcare Solutions
CEO/Principle Consultant
P: 615-397-5042
Disclaimer: My thoughts are my own and do not represent any practice or system.
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