Physician Alignment and Performance Compensation { Mary Ellen Pratt Midsouth CAH Conference St James Parish Hospital August 2018
Objective Discuss the Drivers for Change Elements of Compensation Models SJPH Examples: Performance Compensation for Hospital Based Physicians (PSAs) Performance Compensation for Employed Physicians Lessons Learned
Transformational Change in Medicine
Current Compensation Structure { { AMGA Survey* MGMA Survey* 31% respondents have incentive compensation Patient Satisfaction Clinical Outcomes Effectiveness Citizenship Family Practice Percent of Compensation Quality Patient Satisfaction Sullivan Cotter & Assoc.* 0% were adding value measures within next year * 201 Survey Data
Best Practices in Physician Compensation Align with goals and payment systems- today and future Pay for work and production with evolving definitions Commercially reasonable activities Market competitive Fair Market Value (total Comp) Consistent & Equitable Simple & Understandable Adaptable Compliant
St. James Parish Hospital Midway between New Orleans and Baton Rouge $58 million gross revenue 90% is outpatient ADC of 10 ER sees over 1,000 visits/yr 6 Clinics, 25,000 visits 3 Family Practice General Surgery Urology Urgent Care
SJPH Hospital-Based Physician Performance Pay Process Started in 2010 Paid Monthly (ER) & Quarterly (Hospitalist) Measures determined jointly and with staff input, change periodically Quality measures Patient Satisfaction Efficiency Safety Amount of Performance Comp is based on points scored or benchmarks met
ED Services Monthly Performance Pay Model Baseline pay Base + $5 current rate-meets one or less benchmarks meets a minimum of 2 benchmarks Base + $10 meets 3 benchmarks Base + $15 meets benchmarks Base + $20 meets 5 benchmarks
ED Services Monthly Performance Goals Monthly Benchmarks Definition 1 Patient Satisfaction > 89 mean score Individual MD score or All Doctors Section 2 Door to Provider Time = 30 min (Monthly Average) Time between earliest arrival time in CMR and being seen by a physician 3 Patients per hour = 2.0 Excludes any hour of the day when there are no patients registering to be seen 5 Total TAT 10 minutes (Monthly Average) Admit Decision to ED Departure 60 min Time between the earliest arrival time in CMR and time nurse documents patient left the ED Time from MD admit decision to departure from ED to floor
Aug-15 Oct-15 Dec-15 Feb-16 Apr-16 Jun-16 Aug-16 Oct-16 Dec-16 Feb-17 Apr-17 Jun-17 Aug-17 Oct-17 Dec-17 Performance Metrics Met 1 12 10 8 6 2 6 5 5 7 2 5 6 5 6 6 5 5 7 5 5 7 8 5 3 5 3 2 1 0 0
Hospitalist Performance Pay Model 100% 2 points 75% 23-16 points 50% 15-8 points 0% <8 points
Hospitalist Performance Measures Quality Indicator Physician Specific Core Measures required by CMS CMS HCAPs always MD communication Discharge Summary History & Physical Progress Notes Do Not Use Abbreviations 3 Points 2 Points 1 Point 0 Points All Core Measures above 100% Above Louisiana State average 90% completed and signed within 3 days of discharge 100% completed and signed within 2 hours of admit 100% documented / signed same day Never used in sample 75%-99% of Core Measures above 100% Within 5 points under the LA Avg 75-89% completed and signed within 3 days of discharge 90-99% completed and signed within 2 hours of admit 75-99% documented / signed same day Found 1-3 times in sample 50%-7% of Core Measures above 100% Within 10 points under the LA Avg 60-7% completed and signed within 3 days of discharge 80-89% completed and signed within 2 hours of admit 50-7% documented / signed same day Found 3-5 times, in sample Less than 50% of Core Measures above 100% 10 points or more under the LA Avg Less than 60% completed/signed within 3 days Less than 80% completed/signed within 2 hours <50% documented /signed same day Found 6 or more times in sample CPOE 90% orders 75-89% orders 60-7% orders <60% orders Verbal Orders <10% of sample 10-2% of sample 25-9% of sample >50% of sample Maximum Potential Points 2 16 8 0
Hospitalist Performance Experience 25 Points Avg = 17 points/quarter, 75% of Incentive Comp 20 15 10 5 0
Family Practice Performance Pay Process Started in 2016 Blends Value & Volume Incorporated into compensation (not add on) Modeled after MIPS domains Quality (Hedis) MU Efficiency Improvement Measures determined jointly Paid Annually, measured periodically Added Shared Rewards
Employed Physician Performance Pay Model Varies by Specialty Performance ranking Practice maturity MFV
Family Practice Performance Pay Model 100% 62.5% 25% 0% 22-27points 21-16 points 15-10 points <10 points $16,000 $10,000 $,000 $0
FP Performance Measures MIPS/ Quality MIPS/ Quality MIPS/ Quality MIPS/ Quality Quality Measure Target 3 Points 2 Points 1 Point 0 Points Description Diabetes Care- HbAic >8% Breast Cancer Screening >80% Colorectal Cancer Screening >78% Diabetes Care-Eye Exam >72% >8-6% 63%-33% 32-12% <12% >80-60% 59%-29% 28%-8% <8% >78-58% 57%-27% 26%-6% <6% >97-77% 76%-6% 5%-25% <25% Physician must ensure each patient with DM (type 1 or 2) 18-75 years old has an HbA1c level of no greater than 9. Physician must ensure each female patient 50 to 7 years old has had a mammogram to screen for breast cancer during the measurement year or in the 15 months prior. Physician must ensure each patient 50 to 75 years old receives a colorectal cancer screening test. Appropriate screenings are defined as any of the following: Annual fecal occult blood test during the measurement year. Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year. Colonoscopy during the measurement year or the nine years prior to the measurement year. FIT-DNA test (Cologard) during the past 3 years. CT Colonography during the past 5 years. Physician must ensure that each patient 18 to 75 years old with DM (type 1 or 2) had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal exam in the 12 months prior to the measurement period.
MIPS/ Quality MIPS/ CPIA MIPS/ CPIA MIPS/ACI Same Day Encounter Close Rate Attend Meetings Quality Measure Target 3 Points 2 Points 1 Point 0 Points Description Hypertension >80% >80-60% 59%- 28%-8% <8% Physician must ensure patients who are 18 years of Control 29% age and above who were screened for high blood pressure AND a recommended followup plan is Documentation of Current Medications Annual Wellness Visit 50% Perform medication reconciliation at transfers of care Encounter Close Rate Meeting Attendance FP Performance Measures 100% 100%- 80% 100% 100%- 80% 90% 100% 100% documented based on the current BP reading. 79%- 8%-28% <28% Documentation of current medications in the 9% medical record. Physician will documents a list of current medications to the best of their knowledge and ability. Physician should review and/or update the documented list of current medications in the medications tab during the encounter. This must happen at every visit and each visit counts separately for the measure. 50%- 39%- 28%-18% <18% Physician performs annual wellness visit on 0% 29% patients who have Medicare insurance. 79%- 8%-28% <28% 9% Physician will reconcile the patient s medication list in the new patient encounter or in the first visit after receiving the summary of care record. Same Day Encounter Close Rate is calculated by totaling the number of checked-in appointments 90% 89-85% 8-80% <80% associated with clinical encounters and where the rendering provider is a "person" based provider, then dividing by the number of clinical encounters which have a same day close date during the reporting month. 75% 50% <50% Physician will attend clinic physician meetings 3 2 1-0 times a year.
Lessons Learned Know where your are (FMV/Quality) and share it with physicians Start with what you are already focused on, then expand Align drivers of value-based revenue with value-based incentive measures Make sure the measures are factors the MD can influence Ensure measures are meaningful to MDs Pace change in compensation structure with changes in reimbursement environment don t be too far ahead or behind. (Blend of FFS/VB) Don t pass on 100% of payor incentives Be mindful of laws Stark Anti-kickback Tax Exempt