CMS 2015 - Putting Your Money Where Their Mouth Is

On January 26, 2015, CMS announced through its Better Care, Smarter Spending, Healthier People campaign, a tectonic shift away from volume-based medicine toward value-based medicine. Instead of getting paid more for doing more, physicians in all specialties, including dermatology, will get paid for showing better outcomes. By 2016, roughly 85 percent of Medicare fee-for-service payments may be tied to quality.

So, how does CMS intend to measure quality for dermatology?

First, instead of pay for reporting, which is how PQRS is structured now, PQRS will become pay for performance. In other words, the numbers that a dermatologist reports will become the measure by which several percent of that dermatologist’s reimbursements are determined. Groups of more than nine physicians who bill out more tests and procedures compared to their peers but have a low PQRS performance in 2015 can be penalized four percent of Medicare reimbursements in 2017. Groups of more than nine physicians who spend less on tests and procedures compared with their peers and show a high PQRS performance will be paid an incentive in 2017. And those who fail to report any PQRS in 2015 get docked between four percent (1-9 doc groups) and six percent (10 or more doc groups) in 2017.

Second, let’s not forget about Meaningful Use requirements. The carrots are going away and the sticks are coming out. In 2015, if Meaningful Use data is not reported, doctors stand to lose another three percent in reimbursements from Medicare in 2017. When added together, that’s a seven to nine percent Medicare penalty for those who choose not to participate in PQRS and Meaningful Use. That could quickly add up to $50,000 per provider.

It is has been reported that one-third of dermatologists still do not use EMRs. Of the dermatologists who do have EMRs, a substantial number did not participate in PQRS or Meaningful Use. It stands to reason that these dermatologists must have a good reason, since $50,000 in potentially lost revenue is quite a lot. According to Forbes, doctors who have long resisted adopting EMRs have done so because many of the systems out there are difficult to use and don’t provide much advantage over paper.

“We know from long experience in other sectors that dumping big, clunky, computer systems on to the work of skilled professionals doesn’t save costs. It increases them,” wrote technology expert Steve Denning in the April 25, 2013 edition of Forbes. “What is needed is easy-to-use software that fits the way doctors work and makes their working lives easier and better.”

Besides an easy to use and intuitive EMR, doctors now also need a system that quickly automates Meaningful Use and PQRS reporting. Every year the stakes are getting higher. Luckily, the technology is getting better.

Paper and EHRs that rely on old technology don’t record what is known in the tech world as “structured data.” This is the way CMS requires that the data be reported to them. So, doctors who use paper or these older systems will be forced to double enter data—one as unstructured (in their old charting system) and one as structured to report to CMS. What a waste of time!

But measuring quality doesn’t necessarily mean sacrificing efficiency. For example, Modernizing Medicine simply takes the note you’ve already written and generates the Meaningful Use and PQRS-ready data for reporting. That’s easy for our EHR, called EMA, to do and virtually no work for the doctor, because the data captured is already in a “structured” format. Using an EHR that captures data in a structured format the first time around is a must.

But what if you don’t have a lot of Medicare patients? Perhaps you are thinking that PQRS and Meaningful Use reporting won’t impact you that much. Enter ICD-10.

More Money, More Problems

If $50,000 doesn’t sound like a lot of money to forego, how about $100,000 or more? Welcome to October 2015 and ICD-10—where billing will become an impossibility without automation. Unless you don’t accept insurance, the change to ICD-10 will require another tectonic shift in how you bill. Where ICD-9 has 13,000 codes. ICD-10 has more than 120,000. You can either hire another person to spend his or her day looking up each code or you can let your EHR do it for you.

Again, here’s where having data in a structured format the first time around saves a whole lot of time later. For example, EMA’s ICD-10 coding system uses the diagnoses you’ve already decided on to find the codes for your patient’s visit. No more time or clicks needed to be an ICD-10 billing whiz.

And if ICD-10 wasn’t confusing enough, billing rules are also becoming more convoluted. Over the past year, carriers have been targeting overutilization of the 25 and 59 modifiers, which lead to hundreds of millions of dollars of inaccurate payments. Dermatologists utilize both of these modifiers more than any other specialty. Instead of relying on the CCI edits to place the 59 modifier on the correct procedure code, insurers now need an anatomic specific modifier or an X modifier in lieu of the 59. Again, structured EHR systems already know the location of the lesion based on your exam, which automates placement of the XS modifier.

Ultimately, paper has been popular because it doesn’t distract the doctor from the reason he or she is in the exam room—caring for the patient. No matter what the billing rules or payment structures, EMRs must adhere to the rule that the best technology is the one that doesn’t get between the patient and the physician. Newer systems like EMA, which are built to capture structured data will be the key to maintaining efficiency and improving quality in this brave new world. In 2015, dermatologists can’t afford to stick with paper or their old systems anymore. n

Michael Sherling is the co-founder of Modernizing Medicine and a practicing dermatologist in Lake Worth, FL.