In a recent article just published in the Wall St. Journal, (“Should Physician Pay be tied to Performance?”) two points of view were expressed; the first stated that companies like Health Care Incentives Improvement Institute argue that there are enough bench marks for quality to begin paying Physicians based on outcome. The second opinion expressed by a Physician is very clear that the Cochrane Collaborative reviewed medical evidence and found “no evidence that financial incentives can improve patient outcomes”. Furthermore Health Systems Management Network, Inc., a Practice Management Company operating for thirty years, has found in its experience that pay for performance undermines the very mindset required for good doctoring, that is, the drive to do good work even when no one is looking. With financial incentives it forces Physicians/Clinicians to shift their attention away from patient to computer screens. In our experience patients vote with their feet and by the reputation of the Clinicians. From these articles and discussions something else emerges. There will be a push to try to incentivize quality just as there is a push in the Affordable Care Act to save dollars that can then be shared by the Physician Group and Hospital. In the long run, the only way that has been proven to save money is to provide barriers to expensive care settings.
In HSMN’s thirty years of being consultants to many large and small clinical practices the firm has found that Clinicians want to do their best but they do not always know with any metrics how well they are doing. While the Electronic Medical Record has helped in that regard, it hasn’t solved the problem of individual practices large or small knowing how well they are doing except through patient feedback. HSMN in its many years of practice has found a very large impediment to Physician Practices which have affected their reimbursement and in the future their ability to cite any metrics on the quality of the care they provide.
Putting aside for the moment the issue of the kind of contracts clinical practices have with third party payers is the issue of excellent clinical documentation and the ability to translate their resource use into appropriate reimbursement. Our study over hundreds of practices tells us that every practice that has focused on clinical documentation improvement have increased their reimbursement by five or ten percent. This has not been the result of buying new software or the Electronic Medical Record but rather of carefully parsing cases and looking at the critical elements of diagnoses, interventions and adding outcomes.
Clinical Documentation Improvement is the key to success and having a properly trained staff makes the difference. The staff has to be reoriented and clearly interact with the Clinicians to understand what they do. In other words in HSMN experience, the Physician/Clinicians must be the teachers of staff who can become Clinical Documentation Specialists. Some have argued that hiring nurses to help with documentation is one way to go. HSMN’s experience is that a person be hired into the practice with coding certifications who can then do chart reviews not only about coding but about the actual documentation. Such programs have been very beneficial to practices throughout the country where the Clinicians do not want to be owned by anyone but rather want to continue doing clinical work as their boss.