Reimbursements are changin

[physasst]

Just had a conversation with someone at another academic institution, and they are estimating that reimbursements under the new models (most are moving to some type of bundling, IE; Prometheus payment model) with the ACO construct will fall by 20-40% in the next 5-10 years, all while increasing the number of patients seen.

 

That's huge, and speaking to some others at other institutions, who will only speak confidentially, likely very, very accurate.. I know that we are having internal discussions about the healthcare crossroads we are at, and how to re-design our care delivery. Do patients need to be seen for re-checks as often as they are? Can some be managed remotely? Can some be RN only visits?

 

Essentially, how do we deliver team-based care, high quality care, while expecting lower reimbursements?

 

Lots of questions here. Personally, I don't see PA salaries falling (physicians are another story), but I expect we will see significant wage stagnation in PA salaries....like no raises for many years once this drop in reimbursements starts, and new PAs may see lower salaries offered initially...Physicians may not only see a salary cut, but may see a reduction in positions, as institutions move towards more and more PAs and NPs.....IE; physician dies, retires, or emigrates, and their position may be eliminated or converted to a PA/NP position.

 

Not trying to scare anyone, but thought that the discussion was interesting, and noted how consistent it was talking to people across institutions.

 

It makes me think of the new saying....the OR/SE folks will inherit the earth. Or at least healthcare.

 

Mike

[marktheshark89]

http://innovation.cms.gov/initiatives/bundled-payments/index.html

[Gordon, PA-C]

Just had a conversation with someone at another academic institution, and they are estimating that reimbursements under the new models (most are moving to some type of bundling, IE; Prometheus payment model) with the ACO construct will fall by 20-40% in the next 5-10 years, all while increasing the number of patients seen.

 

Based on what evidence? A gut feeling? I'm not saying they're wrong, I just dont see how you can come up with that kind of number since these new arrangements are black boxes at this point and the details havent been worked out.

 

Personally, I don't see PA salaries falling (physicians are another story), but I expect we will see significant wage stagnation in PA salaries....like no raises for many years once this drop in reimbursements starts, and new PAs may see lower salaries offered initially...Physicians may not only see a salary cut, but may see a reduction in positions, as institutions move towards more and more PAs and NPs.....IE; physician dies, retires, or emigrates, and their position may be eliminated or converted to a PA/NP position.

 

I dont believe it is possible for MD salaries to fall without also affecting PA salaries. The majority of PAs are employed under a physician leader -- you think the physician leader is going to take a pay cut and not pass that along to the PA? I dont see that happening. You may be correct that PAs employed directly by hospitals with non-MD leadership could be more insulated from pay cuts, but even in that scenario if the physicians employed by that facility bring in reduced reimbursements over time that will also filter down to the PAs as well.

 

 

On a larger note, I think that regardless of how the model for payment changes, there will be MDs and PAs who actually find a way to take advantage of the system and use it to make MORE money than they did previously. The government regulators that are proposing these changes dont understand how healthcare is delivered, and in their ignorance they will INEVITABLY create holes that can be exploited for large financial gain. After a few years they will tighten it up, but then providers will find other loopholes to exploit. This is inevitable when you have a centrally planned healthcare system. The regulators cant react fast enough to keep the provider reimbursement in check.

 

IMHO the only way to avoid this "gaming" is to get rid of FFS ENTIRELY and pay providers a flat salary ONLY with no production bonus.

[physasst]

Based on what evidence? A gut feeling? I'm not saying they're wrong, I just dont see how you can come up with that kind of number since these new arrangements are black boxes at this point and the details havent been worked out.

 

Based on different modeling constructs. Now that the rules for hospital reimbursement and practice reimbursement have been released via CMS, different simulation modeling has been conducted. In addition, FFS IS going away. Many insurers and states are looking at bundled models of payment, similar to CMS and in some places Prometheus.

 

I dont believe it is possible for MD salaries to fall without also affecting PA salaries. The majority of PAs are employed under a physician leader -- you think the physician leader is going to take a pay cut and not pass that along to the PA? I dont see that happening. You may be correct that PAs employed directly by hospitals with non-MD leadership could be more insulated from pay cuts, but even in that scenario if the physicians employed by that facility bring in reduced reimbursements over time that will also filter down to the PAs as well.

 

Yes, they will, but I was thinking of the PA employed by the institution.

 

On a larger note, I think that regardless of how the model for payment changes, there will be MDs and PAs who actually find a way to take advantage of the system and use it to make MORE money than they did previously. The government regulators that are proposing these changes dont understand how healthcare is delivered, and in their ignorance they will INEVITABLY create holes that can be exploited for large financial gain. After a few years they will tighten it up, but then providers will find other loopholes to exploit. This is inevitable when you have a centrally planned healthcare system. The regulators cant react fast enough to keep the provider reimbursement in check.

 

IMHO the only way to avoid this "gaming" is to get rid of FFS ENTIRELY and pay providers a flat salary ONLY with no production bonus.

 

There may be some gaming, but not as much as now. Interestingly, most of the modeling that has been done has shown that complicated, rare, difficult cases may still earn top dollar, as it will not be possible to bundle them, but it's the straightforward care that most patients need and receive that will see a drop in reimbursement. A sort of forced capitation if you will. All I can say, is every administrator I've talked to in different regions of the country is freaking out a little bit.

 

More nurse visit only occurences? PAs and NPs seeing more and more, primarily follow ups.....physicians ONLY seeing new patients and new workups?

 

One thing that several are talking about is an increase in telemedicine and remote visits. Won't get paid for the in-person visit anyways, so perhaps E-Consults, email, telephone visits, and remote video visits will start to occur....

 

It's going to be an interesting next several years....

[physasst]

Here's a recent article from our CEO...

 

http://www.bizjournals.com/twincities/news/2013/02/27/mayo-clinic-reports-revenue-increase.html

 

I think this will definitely impact PA salaries...

[treejay]

Well... With widespread discussion about the need to curtail healthcare costs, it seems a no-brainer that those working in healthcare will see a decrease in income. You can't curb healthcare costs and expect to make the same. how would that mathematically pencil out ?

[physasst]

Well... With widespread discussion about the need to curtail healthcare costs, it seems a no-brainer that those working in healthcare will see a decrease in income. You can't curb healthcare costs and expect to make the same. how would that mathematically pencil out ?

 

The sarcasm is duly noted. I don't think any of us are surprised by the decrease in reimbursements. I spent several years working on this. I think what has surprised all of us, myself included, was the rate of decline. The initial estimates that we were having in discussions in a national workgroup were closer to 8-12%. 20+% was a bit of a shock. That was the point of this post.

[treejay]

The sarcasm is duly noted. I don't think any of us are surprised by the decrease in reimbursements. I spent several years working on this. I think what has surprised all of us, myself included, was the rate of decline. The initial estimates that we were having in discussions in a national workgroup were closer to 8-12%. 20+% was a bit of a shock. That was the point of this post.

 

Actually, I wasn't intending to be sarcastic nor intended to direct the post towards anybody in particular. I think it was more a fascination in the ongoing dialogue by many different people (clinicians, politicians, ordinary people, etc) in the need for cutting healthcare costs, but far less dialogue regarding who is going to bear the brunt of those cuts (i.e. healthcare workers including PAs, docs, nurses, NPs, everybody). That's been my experience at least. Perhaps it's just an unspoken acknowledgement? Perhaps it's because that sort of dialogue rapidly becomes more unpopular and get more push back from those at stake? I'd be curious to hear people's thoughts...

[physasst]

Actually, I wasn't intending to be sarcastic nor intended to direct the post towards anybody in particular. I think it was more a fascination in the ongoing dialogue by many different people (clinicians, politicians, ordinary people, etc) in the need for cutting healthcare costs, but far less dialogue regarding who is going to bear the brunt of those cuts (i.e. healthcare workers including PAs, docs, nurses, NPs, everybody). That's been my experience at least. Perhaps it's just an unspoken acknowledgement? Perhaps it's because that sort of dialogue rapidly becomes more unpopular and get more push back from those at stake? I'd be curious to hear people's thoughts...

 

Well, part of the problem is that people often blame physician salaries for rising healthcare costs, but this ignores the fact that there is an estimated 30% waste, fraud, and abuse in the system, and that physician/provider salaries only account for about 11% of total healthcare spending. This is why this focus may not be a high yield. We need to dramatically reduce testing and the use of all of this expensive technology. Anecdotally, this is an area ripe for research in the PA arena. Audit and Feedback that is.

 

For example, I had a PA send me an unpublished study that he completed looking at whether EM PAs followed the Ottawa Ankle Rules. It was a decent paper, but suffered from a small sample size and used self reported data which is always suspect for bias.

 

However, it was noted that 70% of PAs practicing in EM did NOT follow the Ottawa Ankle Rules. There were a number of reasons cited, but the bottom line is, this has to change.

 

I can see a day in the not very distant future where your reimbursements will be tied to your ability to follow these guidelines. IE; You obtained ankle xrays on someone did not have positive criteria, and the xray will not be paid for. Stay tuned...this is coming relatively soon (5-7 years)......

[EMEDPA]

I would like to say I use ottawa 100% of the time but the truth of the matter is this:

a pt with an obvious ankle sprain has been waiting for 4 hrs to be seen.

all they really need is an ace wrap and motrin. most mom's know this.

they expect an xray.

if they don't get one they will give you bad press ganey scores and say things like " I waited 4 hrs, didn't get an xray, and had to see my regular dr the next day to get an xray to find out that it wasn't broken".

your chief yells at you for bad PG scores.

next time your order the wasteful xray to avoid the above hassle.

PG scores as noted elsewhere in em are totally worthless because the happiest pts(those who get big workups and are admitted) don't get to fill out a survey. the folks who get the surveys are the drug seekers with dental pain at 3 am that you refuse to give oxycodone to. one of our docs, just to prove this point, decided that for a period of 1 yr he would give perocet to anyone who asked for it. his PG scores went from worst in the dept to best by a huge margin.

[treejay]

I would like to say I use ottawa 100% of the time but the truth of the matter is this:

a pt with an obvious ankle sprain has been waiting for 4 hrs to be seen.

all they really need is an ace wrap and motrin. most mom's know this.

they expect an xray.

if they don't get one they will give you bad press ganey scores and say things like " I waited 4 hrs, didn't get an xray, and had to see my regular dr the next day to get an xray to find out that it wasn't broken".

your chief yells at you for bad PG scores.

next time your order the wasteful xray to avoid the above hassle.

PG scores as noted elsewhere in em are totally worthless because the happiest pts(those who get big workups and are admitted) don't get to fill out a survey. the folks who get the surveys are the drug seekers with dental pain at 3 am that you refuse to give oxycodone to. one of our docs, just to prove this point, decided that for a period of 1 yr he would give perocet to anyone who asked for it. his PG scores went from worst in the dept to best by a huge margin.

 

Right. In an era of customer satisfaction scores holding much weight combined with a fear (rightly justified or not) of litigation and the CYA mentality that it breeds, it seems that the incentive to perform extra tests is high. And of course, speaking of incentive, can't ignore the economic incentive to perform tests in the current fee for service model

[Guest Paula]

I would like to say I use ottawa 100% of the time but the truth of the matter is this:

a pt with an obvious ankle sprain has been waiting for 4 hrs to be seen.

all they really need is an ace wrap and motrin. most mom's know this.

they expect an xray.

if they don't get one they will give you bad press ganey scores and say things like " I waited 4 hrs, didn't get an xray, and had to see my regular dr the next day to get an xray to find out that it wasn't broken".

your chief yells at you for bad PG scores.

next time your order the wasteful xray to avoid the above hassle.

PG scores as noted elsewhere in em are totally worthless because the happiest pts(those who get big workups and are admitted) don't get to fill out a survey. the folks who get the surveys are the drug seekers with dental pain at 3 am that you refuse to give oxycodone to. one of our docs, just to prove this point, decided that for a period of 1 yr he would give perocet to anyone who asked for it. his PG scores went from worst in the dept to best by a huge margin.

 

And I bet he had flocks of people circling the parking lot to see if his car was there so they could get their percs. Did he change back to his prior prescribing habits?

[EMEDPA]

. Did he change back to his prior prescribing habits?

yup. and no one bugged him about PG after that. I wouldn't recommend trying this as a pa however as admin will yell at you for writing too many narcs as well as writing only limited (appropriate) narcs.

[mdebord]

I'm having a slightly different issue with the change to bundling that I'd like opinions on, but I think it ties in with the original theme from the OP. We had drama this week at our monthly group meeting (all the providers and admin get together). Basically, our leader was explaining that they are going to try to restructure the schedule so that the docs see the managed care pts in 30 min appts. The midlevels would handle acute visits. Now, as it currently stands, I see about 85% acute visits anyway, but it is those chronics that really challenge me to grow. Here's my issue: I can completely understand how this makes financial sense and even would likely provide better care for the patients. But that is not the work I want to do. If this became a reality, I would seriously consider switching away from Family Practice (and we all know that's the trend already). Do y'all see this happening already?