schrute

RoyalCrownChinpokoMaster
10+ Year Member
Feb 12, 2007
414
15
Status
Attending Physician
I keep reading about this, for example in the WSJ a few days ago about Gov. Jindal's Louisiana paying a "...fixed per-patient amount, adjusted for health risks."

How does a program like this affect pathology?
 

Nilf

15+ Year Member
Mar 20, 2003
717
19
Dancing on the graves of my enemies
Visit site
Status
Attending Physician
I keep reading about this, for example in the WSJ a few days ago about Gov. Jindal's Louisiana paying a "...fixed per-patient amount, adjusted for health risks."

How does a program like this affect pathology?
Yeah I read about this concept; Daschle mentioned it in his book.

It merely adds another tool to the insurers' armamentarium to deny payment. Nothing else, no matter what specialty.
 

yaah

Boring
Staff member
Administrator
15+ Year Member
Aug 15, 2003
27,934
309
Fixing in 10% neutral buffered formalin
Status
Attending Physician
Pathology is already affected by fixed-rate compensation for services (inpatient and some outpatient categories). Hospitals receive a certain amount of money for inpatient admissions based on the diagnostic category, this amount will be the same if the patient stays 5 days or 15 days, whether they have 20 tests or 2000 tests. Pathology can bill for tests that are done but it is basically just to fight for a piece of the general reimbursement that goes to the hospital, and "prove" that the department deserves it. Stuff like this proposal above probably affects pathology less significantly than other fields, but anything that hurts reimbursement in general will hurt pathology.
 

HESC

remaining pluripotent
10+ Year Member
5+ Year Member
Dec 5, 2007
69
0
Status
Resident [Any Field]
Outcomes based compensation is a "pay for perfrmance" (P4P) model which reimburses based on whether a good outcome was obtained or if "quality measures" were taken to ensure quality care.

The system must be adjusted for comorbidities and other risk factors to stratify the reimbursements fairly. Example, a 300 lbs person with hypertension reaching the blood pressure goal of <130/90 is not as likely as a fit person reaching the goal, so the physician should be reimbursed for makin a reduction in the fat persons BP and not soley based on if the goal was acheived.

I think CMS has some P4P for path like breast ca, and colon ca lymph node counts.

This kind of reimbursement model might be the way things are done in the future. It seems though that path labs have way more control over quality issues than say a family practice doc that works in a poor socio-ecomonic area whose patients are uneducated and don't take care of themselves anyway....
 

HESC

remaining pluripotent
10+ Year Member
5+ Year Member
Dec 5, 2007
69
0
Status
Resident [Any Field]
Pathology is already affected by fixed-rate compensation for services (inpatient and some outpatient categories). Hospitals receive a certain amount of money for inpatient admissions based on the diagnostic category, this amount will be the same if the patient stays 5 days or 15 days, whether they have 20 tests or 2000 tests. Pathology can bill for tests that are done but it is basically just to fight for a piece of the general reimbursement that goes to the hospital, and "prove" that the department deserves it. Stuff like this proposal above probably affects pathology less significantly than other fields, but anything that hurts reimbursement in general will hurt pathology.
i think this is more of a "Diagnosis related group" (DRG) than an outcomes based compensation model....

Plus, From what I understand, if the pathologist did the proper amount of lymph node evaluation in a colon ca case for all the CRC cases then they would be entitled to a small % of all CMS fees billed from the pathologist for the year. So, that may be a huge bonus for some docs! P4P may suit pathology very well...
 

yaah

Boring
Staff member
Administrator
15+ Year Member
Aug 15, 2003
27,934
309
Fixing in 10% neutral buffered formalin
Status
Attending Physician
Except that whole lymph node harvest thing to me seems based on flawed conclusions of data. Not all colons contain the same number of lymph nodes. You can spend eight hours on some sigmoid colons or rectums and never find 10 nodes.

And yes, I was referring to DRG above, but seems to me like most of the reimbursement issues and probably future outcomes based compensation would revolve around this anyway. So pay for performance may not really matter except for the patient at large. Pathology may then claim they have a right to more of the billing revenues, but it doesn't mean anything tangible.

But quality issues may be very relevant on outpatient tests like biopsies.