WASHINGTON – Eliminating the service fee reimbursement would greatly contribute to reducing diagnostic errors, said David Newman-Toker, MD, PhD, on Tuesday at the annual Medicine Diagnostic Error conference here.
"The service fee payment structure is, in my opinion, toxic for diagnosis," said Newman-Toker, professor of neurology, ophthalmology and otolaryngology at Johns Hopkins University in Baltimore. "The general theory says that the service fee cannot be bad because it does not discourage order tests, so you can request any test you need to make the correct diagnosis. However, it encourages you to do more tests instead of proof. correct, and encourages him to go fast and be thoughtless, "he said. "It is cheaper to order each test in advance, and worry about solving it later, than being careful and just ordering what the patient needs."
And if the staff decides that it will work to not order unnecessary tests, "the business office says: & # 39; How much are we going to lose with that? & # 39;", he added.
Will not leave soon
But not everyone agreed with him. "I wouldn't give up the service fee; we won't eliminate it immediately (anyway)," said Mark McClellan, MD, PhD, director of the Duke-Margolis Center for Health Policy in Durham, North Carolina. He noted that the Centers for Medicare and Medicaid Services (CMS) recently announced the conclusion of their multi-year process to update the Medicare reimbursement and management reimbursement codes.
"There was a fairly significant change in the (numerical) weight placed, especially in cognitive and support services, such as spending more time with the patient to make sure he has the right symptoms and following an analytical approach to address the problem."
"For cognitive specialties such as internal medicine, it means an increase of 10% or more in payment rates, according to the latest CMS analysis," said McClellan. "Some steps have also been taken towards greater coding of the type of service fee for more person-centered care and more time associated with patient care, spending time with patients. That is easier to do when the system general payment is less about the volume and more about the general cost of care and results. "
Newman-Toker, president of the Society to Improve Diagnosis in Medicine, described the many costs associated with diagnostic errors, and noted that about 12 million such errors are calculated each year, with costs exceeding $ 100 billion and more than 500,000 injured patients. "It is a huge problem, one that we must recognize and one of the most critical and neglected issues in medicine and patient safety."
Taking a different approach
Part of the problem is the difficulty in distinguishing people who seem to be sick, but who are not really sick, from people who do not seem sick but are, he continued. "If you solve both problems simultaneously, you would be saving lives and saving money." At this time, doctors tend to waver between two perspectives: the "Nellie Nervous", who over-orders the tests to rule out all possible diagnoses, and the "Crazy Cowboy", which orders very few tests and rejects his best guess.
"The truth is that bouncing back and forth between these two perspectives is not improving the diagnosis at all; it is simply exchanging false positives and false negatives with each other," said Newman-Toker. "It's not about doing the same thing, it's about doing it differently and better."
He listed several political barriers to improve diagnoses, including the lack of government funds for research on the subject. "We spend less (on this) than on smallpox research, a disease that was eradicated half a century ago." Although the NIH is excellent for some types of research, "it is terrible to fund studies that differentiate between disease A and disease B". Another barrier: many measures of potential outcomes that address the misdiagnosis have not yet been implemented. And the current accountability structure is organized around diseases rather than symptoms, Newman-Toker added.
According to McClellan, improving payment rates for the use of diagnostic technology would also be useful. "It can be a challenge from the point of view that to develop a diagnostic test, the payment of the test depends on the payments for the time and materials used, not the impact of the test," he said. "That tends to drive the use of efficient, low-cost tests, individually, but not collectively."
Value of alternative payment models
That is why alternative payment models (APMs) "are really a critical step to achieve much faster progress in treating the problem of diagnostic errors in medicine," said McClellan. He described four payment categories:
Category 1: Traditional service fee payment without link to quality and value
Category 2: Payment of service fee under a "performance payment" system, with links to quality and value
Category 3: APM based on a fee-for-service architecture
Category 4: Population based payment
"Most of the current payments are a combination of category 2 and early category 3," he said. "Those make a difference in the dimensions that are measured, but not necessarily a big difference in the general trends in the cost of care and the results that really interest us … It is not a systematic approach to payment reform."
Michelle Schreiber, MD, Centers for Medicare and Medicaid Services (Photo by Joyce Frieden)
Michelle Schreiber, MD, director of CMS Quality Measurement and Value-Based Incentives Group in Baltimore, discussed the idea of using quality measures focused on diagnosis. "A quality measure that I would like to see is related to the CEO and board's commitment to quality and safety," he said. "When you have that commitment, it is who makes the decisions about the allocation of resources."
"We need to make the measures more timely and provide instant comments," Schreiber said. "It has to be less burdensome and flow with the workflow in clinical practice." Several years ago, CMS began a Significant Measures initiative, "to identify a central set of domains in which it is particularly important that we focus," he said, adding that the agency is "committed to focusing on the right measures and to do the most transparent data. "
CMS has also pledged to measure alignment and has been working with the Department of Veterans Affairs, the Department of Defense and among all payers "to come up with a basic set of quality measures that we will all agree to use," Schreiber said. "The work is laboriously slow because there are many stakeholders that have their point of view and it is difficult to let go."
The conference was supported by the Society to improve the diagnosis in medicine.
2019-11-12T18: 00: 00-0500