It's time to get a new yardstick

Why traditional claims data is a bad yardstick.

Like it or not, your practice is already being measured.

It's being measured by people who know nothing about physical therapy using limited, inaccurate data and unfair metrics. And, those flawed measurements are being used to select financial winners and losers.  
One of my favorite examples of the reporting of flawed measurements is the Propublica Treatment Tracker.

If you're a Part B provider for Medicare, Propublica makes it easy to look up data that CMS has compiled on you and your practice. From the treatment tracker website, simply select your state, and then your specialty and your name.

At first glance, the data looks impressive. It includes services performed, number of patients, Medicare payments, average payment per patient, and average services performed per patient, and will rank you against your peers statewide.

When you dig into an individual provider’s data, Propublica ranks the relative complexity of each provider’s patient population along with the frequency of services provided by CPT, dollars billed to Medicare, and payments from Medicare.  
So what’s wrong with this picture? Plenty. 
Most importantly, it is all based on claims data, which is a bad yardstick.

Claims are produced after utilizing all kinds of arcane and complex rules for one overriding reason: to get paid.

Although other data is required on the claim, such as ICD-10 codes and CPT codes, those are of very limited value in discerning quality, and are often an after-thought for the provider. (Do you really list every comorbidity diagnosis code for your patients on your claims?)  
This problem with subpar, meaningless claims data especially rings true for rehab specialties.

As I’ve written in the past, ICD-10 codes describe diseases and injuries. By and large, we treat the sequelae of diseases and injuries, not the disease or injury itself.

CPT codes, published by the AMA, are primarily designed to account for technical procedures for our profession, not professional services, and don’t come close to doing an accurate job of describing the actual services provided.

Worse yet, the most valuable services we provide (thorough evaluations, patient management, counseling, education, etc.) are either not paid at all or are extremely under-valued.

As a result of this and as part of the game we all play in fee for service, we're encouraged to spend more time providing timed technical services (ther ex, manual therapy, etc.) than untimed or non-reimbursed professional services (evaluations, counseling, education, management).   
So, we have codes that are placed on claim forms for the purposes of getting paid in a dysfunctional system that is being used today to make judgments about cost and quality. Worse yet, payers and employers are using that flawed data to make decisions about preferred provider networks. 

In addition to the flawed data problem, we have a well-known perverse incentive problem with fee for service.

The Incentive Alignment Problem
I recently had an opportunity to discuss this problem with one of the largest employers in the country wrestling with physical therapy utilization.

They've noticed that PTs tend to use every visit authorized, regardless of the number of visits authorized. In fact, they said “If our employees are authorized to get 20 visits of PT, they always seem to get 20 visits of PT.”

My response? “Of course!"

That's the way incentives are aligned. PTs fight and scrape to get patients adequate treatment every day, and many of them don't. When you have a rare instance of a generous pre-auth, it isn’t at all surprising that all of the visits tend to get used.

The good news: CMS and commercial payers have gotten the message. Instead of relying on claims-based data from a fee for service system, there is a steady transition to measurements based on clinical quality.

And, more of that data will be available to the public than ever before.  

Among the mandates of the Affordable Care Act was helping consumers make informed decisions about the healthcare they receive. That mandate resulted in the development of the Physician Compare website.

From CMS: “Medicare patients and caregivers are able to use the Physician Compare website to search for and compare clinicians and groups who are enrolled in Medicare. The Physician Compare website also incentivizes clinicians to maximize their performance by making performance information publicly available.” 
Currently, the information available on the site isn't very comprehensive, as it only includes demographic information, contact information, and educational background of providers, but very soon it will include quality data from the MIPS program. Exciting stuff. 
MIPS itself is changing.
There's a definite shift away from “process based” measures that you may be familiar with from the old PQRS program (like medication list, falls risk, falls plan of care) to patient reported outcomes measures.

And, CMS is taking steps to make quality measures, activity improvement projects, cost, and interoperability more meaningful to clinicians through the MIPS Value Pathways.
The move from volume to value is real. The pace of change is accelerating. Measuring outcomes is changing from best practice to a requirement.  
Time to get a new yardstick. 
I'd love to hear your thoughts. Share them with me over on Twitter.


P.S. I talked about the evolution of MIPS for 2020 with Holly, Keet’s fearless leader, in a recent webinar. Catch the recording here

Bring Out Your Dead

Pre-P.S. We’d like to introduce you to Jerry Henderson. He’s one of the co-founders of Clinicient, our parent company. He was a PT for over twenty years until he switched gears and began building Clinicient after seeing a gap in the market for an EMR software built specifically for outpatient therapy. He’s since helped the company evolve into a market leading EMR and helped expand the family to include us here at Keet and our newest partners Intermountain ROMS. Jerry’s a Keetian through and through, and today he’s taking over the blog.

“Bring Out Your Dead!” is the tagline from one of my favorite scenes from one of my favorite movies, Monty Python and the Holy Grail.

If you’re a Python fan, you likely remember the scene: The film is set in medieval England, and during this sequence, a group of undertakers are slogging through a muddy thoroughfare with a cart of the recently deceased calling out “Bring Out Your Dead!”. An elderly man is about to be thrown on the cart but insists he isn’t dead yet.

Monty Python Bring Out Your Dead GIF

Like the “Dead Man” in this scene, fee for service is terminally ill. It isn’t ready for the “Dead Collector” quite yet, but it’s close.

MIPS is Just the Beginning

If you’ve heard me on one of the Keet webinars, you know I’m repeating myself, but I think this bears repeating: MIPS is important—it’s also just the tip of the iceberg. MIPS signals the beginning of the end for fee for service. It’s the vessel that encouraged the collection of value-driven patient reported outcomes and was the beginning of PTs showing their value much like the rest of the healthcare industry has for years. It opens doors to creative care opportunities previously left closed due to the lack of data. MIPS is a sea change event because it changes the conversation from merely collecting individuals outcomes to driving continuous quality improvement and reporting in aggregate to see trends. It’s what will get us out of fee for service and into models that are beneficial to value-based care.

I feel very fortunate that we had smart players on both the Keet and Clinicient teams who were ready to think bigger than the initial ruling and create a solution that not only meets MIPS requirements but sets a much broader foundation for the industry.

This is the first time I’ve been able to catch my breath since we launched Outcomes and I’m just now feeling the true magnitude of the puzzle that’s beginning to take shape.

Keet and Clinicient Teams

The Clinicient and Keet teams knew early on a qualified registry wouldn’t be enough—we wanted more than that. We knew meeting QCDR requirements would be crucial for our long-term vision and partnering with someone who had a QCDR in place would allow us to move rapidly and place greater focus on the experience for patients and providers—something that so often gets put on the backburner in our industry.

Enter Intermountain ROMS…

With a strong backbone in healthcare innovation, we knew Intermountain ROMS was our partner of choice. We know their years of experience in delivering outcome measures and providing the analytic tools necessary to do more with data was exactly what we needed to add to Keet to create the most robust solutions for the market in year one of MIPS for physical and occupational therapy.

This was a huge team effort that required research; understanding complex requirements and translating those requirements for our clients; development of an innovative, high-value low touch solution; and implementation and training of thousands of new users ranging from front office administrators to therapists to patients.

The Pioneers

I would like to publicly thank the pioneers at Intermountain who developed the ROMS system, especially Gerard Brennan, Stephen Hunter, and Lee Pierce. We wouldn’t have had the ability to support our clients in the MIPS program without their vision and diligent development of a practical and effective methodology for measuring outcomes.

Our Clients

And, most importantly, I want to thank the clients at Clinicient and Keet who were willing to be early adopters of Keet Outcomes and participate in the first year of MIPS for PTs. It’s obvious that none of this would be possible without you.

More to Come!

We are immensely proud of the product we delivered in 2018 to help our clients meet MIPS reporting requirements. With that being said, there is more work to be done, and we couldn’t be more excited.

While it may not be time to “bring out your dead” quite yet, that time is coming sooner than many believe. With fee for service stepping up to the guillotine, it’s time to begin laying the groundwork for your success in value-based programs. MIPS is just the beginning; Outcomes opens up a plethora of opportunity that we can’t wait to explore alongside you.