Thoughts on the "bundled payments" approach?

[DrJD]

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I've heard bits and pieces about bundled payments recently and I was just curious if anyone, with more knowledge than I, had any thoughts on how it would effect Radiologists salaries going forward.

I'm assuming it would largely depend on who decides how the bundle is split?

Also just an ranting aside: I think it is lame that all of the decisions about restructuring medical payment systems going forward are decided by old primary care doctors. They all had practically no debt coming out of medical school and have some sort of grudge against specialists.

 

[radsbuddy]

I've heard bits and pieces about bundled payments recently and I was just curious if anyone, with more knowledge than I, had any thoughts on how it would effect Radiologists salaries going forward.

I'm assuming it would largely depend on who decides how the bundle is split?

Also just an ranting aside: I think it is lame that all of the decisions about restructuring medical payment systems going forward are decided by old primary care doctors. They all had practically no debt coming out of medical school and have some sort of grudge against specialists.

bump!

 

[bronx43]

I've heard bits and pieces about bundled payments recently and I was just curious if anyone, with more knowledge than I, had any thoughts on how it would effect Radiologists salaries going forward.

I'm assuming it would largely depend on who decides how the bundle is split?

Also just an ranting aside: I think it is lame that all of the decisions about restructuring medical payment systems going forward are decided by old primary care doctors. They all had practically no debt coming out of medical school and have some sort of grudge against specialists.

I don't usually engage in ad hominems, but you're an idiot. I knew our medical schools were filled with little children who don't know how the world functions in any way, shape, or form, but you take the cake, son.

 

[Path or bust]

I don't usually engage in ad hominems, but you're an idiot. I knew our medical schools were filled with little children who don't know how the world functions in any way, shape, or form, but you take the cake, son.

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

 

[Columnar]

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

I guess they just don't want any doctors. Are these people delusional or simply dense?

Continue cutting payments, sure. Remind me who will go into medicine for a pittance, with 80 hour work weeks, and tons of liability?

Sadly, engineers and consultants are making the same we make now, with a bachelor's.

 

[Silent Cool]

I don't usually engage in ad hominems, but you're an idiot. I knew our medical schools were filled with little children who don't know how the world functions in any way, shape, or form, but you take the cake, son.

Wow, Bronx. No need to be a Jack*****. It's a legitimate reaction, esp. for those with HUGE debt.

 

[bronx43]

Wow, Bronx. No need to be a Jack*****. It's a legitimate reaction, esp. for those with HUGE debt.

It's an ignorant reaction. Having debt (which all of us do) isn't an excuse to be entirely oblivious to the financial and political quandary this country is in, which is largely brought upon by an entirely unsustainable health care sector. Bundled payments are likely not the panacea that we seek, but to be derisive of those trying to come up with new reimbursement strategies as "old primary care physicians" with no debt and a "grudge against specialists" is just ridiculous.

 

[Silent Cool]

It's an ignorant reaction. Having debt (which all of us do) isn't an excuse to be entirely oblivious to the financial and political quandary this country is in, which is largely brought upon by an entirely unsustainable health care sector. Bundled payments are likely not the panacea that we seek, but to be derisive of those trying to come up with new reimbursement strategies as "old primary care physicians" with no debt and a "grudge against specialists" is just ridiculous.

well of course it's not a malicious move by "old docs against specialists" or something, but bundled payments will screw all docs. and while we all have debt, many new grads have ridic. debt.

 

[shark2000]

1- If you cut all physicians income by half, that will only reduce 4-5 % of total health care expenditure. If you see one of hospital bills you will figure out that physician income is almost nothing compared to other expenses.
2- Primary care doctors are underpaid. I always protect them, because they are a colleague. But, if they want to make money by taking out of my paycheck they are not colleague anymore. They started the fight.
3- I'd rather work with NP and PA than primary care doctors. Primary care docs are glorified PAs that do not have anything more than an PA, but EGO. Many PAs work only in few fields and their knowledge depth is more than PCPs.
4- Clearly in the future NPs and PAs starts to encroach on PCP job. PCPs will sink in the same hell they've made for specialist. AMA is an association that actively working to steal money from specialists and they will be successful. But once they are done, their own turn will start. Long story short, the ratio of salaries will remain the same, but all the salaries will be much less. CEOs, Hospital administrators and ... have found AMA as a middle man to implement their goals and eventually they will get back to AMA. Good luck.
4- bronx43 does not know what he is talking about. He is clearly biased against radiology without knowing the infra-structure of the hospital.

We work like a dog for our salary. We deserve every penny that we make. The only reason that I work so hard is the financial incentive. If it is not there, I will not work as hard. Yes, in Europe a radiologist makes half as me (I have close friends there), but on average he reads 40-50 studies which include only 15-20 CTs. Yesterday, I was on call and I read 130 studies, which had 50 CT and MRs.

If the medicine becomes socialized, which may be inevitable, expect 2-3 days for a CT to be done and another 1-2 days to be read. Expect a consult to take 2-3 days to be done. Everything has its own tradeoff. The society should come to the conclusion that high quality health care is expensive and you have to pay for it.

I am very curious to see what will these primary care doctors do with the patient without having lab tests and imaging results ready by the time they want to see the patient. I expect them to vote for increase pay for radiology if it happens.

Good luck,

 

[Browser]

Amen, go Rads. Additionally, I would like to add that two points that go along with the value of Radiologists to some physicians and to society as a whole:
1) Radiologists "cover" other physician's asses on a daily basis (see surgeons) by wording things in code making it more difficult to pin the surgeon on a mistake.
2) Radiology is "seeing" an abnormality that almost nothing else can match in terms of certainty (save cardiac specific troponins and a few other blood tests). With litigation not going away in this country, imaging will only become more essential.

 

[vm26]

http://online.wsj.com/article/SB10001424052970204720204577128901714576054.html

http://www.beckershospitalreview.co...business-professor-to-acos-you-will-fail.html

 

[whatabro]

Interesting problem. Bundled payments do not work in any way for radiologists with the way most practices are set up. Say you pay the GI doctor a bundle of $1000 for a diagnostic colonoscopy with polyp removal. This includes any hospitalizations and complications. The colon gets perforated and now they need a CT scan. Does the $75 for the professional component come out of the GI doc's pocket? Sounds like a winning scenario for everyone.

I've asked at every presentation I've been to on ACO's and bundled payments how this is going to work for "ancillary" type specialties like radiology and pathology. And literally no one has ever been able to answer with any substance. It's amazing. Would love to hear if someone else has actually heard of a scenario where this works.

Granted, for integrated systems like Scott & White, Geisinger, Intermountain, Kaiser, etc, it is different bc the radiologist or pathologist is employed as is the GI, Heme/Onc, hospitalist, whatever. But that's not the majority of health care delivery systems.

 

[shark2000]

Interesting problem. Bundled payments do not work in any way for radiologists with the way most practices are set up. Say you pay the GI doctor a bundle of $1000 for a diagnostic colonoscopy with polyp removal. This includes any hospitalizations and complications. The colon gets perforated and now they need a CT scan. Does the $75 for the professional component come out of the GI doc's pocket? Sounds like a winning scenario for everyone.

I've asked at every presentation I've been to on ACO's and bundled payments how this is going to work for "ancillary" type specialties like radiology and pathology. And literally no one has ever been able to answer with any substance. It's amazing. Would love to hear if someone else has actually heard of a scenario where this works.

Granted, for integrated systems like Scott & White, Geisinger, Intermountain, Kaiser, etc, it is different bc the radiologist or pathologist is employed as is the GI, Heme/Onc, hospitalist, whatever. But that's not the majority of health care delivery systems.

Bundle payment is equal to doctors as hospital employees.

In bundle payment, they pay a flat rate to the hospital. It is not like paying the GI for colonoscopy and then redistribute it from there.

In a bundle payment system, there is no such thing as pay for service. As a result, there will not be any charge code for any procedure. So your assumption that colonoscopy costs 1000 USD is irrelevant.

My best guess is, it will not be implemented. But if they start it in any case, all the physicians will be hospital employees like the models you've mentioned. And probably we will see a huge cut in specialist income with near equalization of payment, something similar to Europe. This will result in doing least for the patient which will decrease the quality significantly. Also we will see turfing out all the responsibilities to other services. I can see that GI docs will send their patients for Virtual colonoscopy left and right. But I don't think this will be the future. For many reasons, this system will fail from the beginning.

 

[badasshairday]

Bundled payments will decimate income in radiology.

CMS is already clamping down hard. 50% reimbursement for repeat imaging on an inpatient is now being recommended to be 25% reimbursement for repeat imaging.

So if a patient gets a CT head, then a repeat CT head due to some new neuro symptoms as an inpatient, you will be reimbursed 25% the value of the original study. Even though you may not have been the radiologist who read the first study and the fact that the patient has new clinical findings.

Get ready to work for peanuts.

 

[shark2000]

Bundled payments will decimate income in radiology.

CMS is already clamping down hard. 50% reimbursement for repeat imaging on an inpatient is now being recommended to be 25% reimbursement for repeat imaging.

So if a patient gets a CT head, then a repeat CT head due to some new neuro symptoms as an inpatient, you will be reimbursed 25% the value of the original study. Even though you may not have been the radiologist who read the first study and the fact that the patient has new clinical findings.

Get ready to work for peanuts.

You didn't get the point. The hospital never get paid for CT scan, ED visit, Neurosurgery consult, GI consult, Neurology consult, Craniotomy, ... separately. In bundled payment, no such thing as pay per service exist. So the hospital will get paid for Epidural hematoma once. Now no matter how many CTs is done, MR is done or not, the hospital will get paid for example 2000 bucks. In this method, there is no such thing as 25 bucks or 50 bucks or 100 bucks for reading the repeat CT.
Most of the doctors will be hospital employees without fee for service. The concept of less money for second CT belongs to the fee for service model of payment. It does not belong to bundle payment.

On the other hand, I agree with your statement about CMS cut. It will be implemented sooner or later, just because bundled payment is not a sustainable model in US healthcare.

Generally speaking, the radiology exams will pay less per study in the future. The flip side is the effect it will have on the volume of studies. Have you ever noticed portable X-rays. They are done very frequently because they are cheap. A study a few years ago, showed they are useless on daily basis in ICU. However, everybody does it because it is considered cheap. Its cost is less than a cost of NG tube. So why not doing it after each NG placement?

Now imagine an MR brain costs 50 bucks. It will be like over the counter aspirin. Then everybody will get one at costco or wallmart.

Imagine a Virtual colonoscopy cost became 200 USD per study. Do you think a GI doc can bill for a colonoscopy for 1500 USD? The same for CTA coronary even if read by cardiologist? The same for many other stuff.

 

[badasshairday]

You didn't get the point. The hospital never get paid for CT scan, ED visit, Neurosurgery consult, GI consult, Neurology consult, Craniotomy, ... separately. In bundled payment, no such thing as pay per service exist.

I did get the point. I was just saying that even if we don't get ripped by bundled payments, we will get ripped by declining reimbursements for fee for service.

 

[shark2000]

I did get the point. I was just saying that even if we don't get ripped by bundled payments, we will get ripped by declining reimbursements for fee for service.

You are right.

I was relatively optimistic about it. In the past week, after meeting with leaders of different specialties, I came to the conclusion that almost certainly the employment model for physicians is the future.

As a result in the short term, you may not see the difference, but in the long term there will be a huge cut in what everybody makes. We will be where Europe is now, probably with a small higher income brackets. This is the bitter truth.

 

[badasshairday]

We will be where Europe is now

Except with a large debt load and malpractice threats.

Live frugral, pay off your debt as you can, and hope for the best.

 

[shark2000]

Except with a large debt load and malpractice threats.

Live frugral, pay off your debt as you can, and hope for the best.

I agree. Though with employment model the legal and malpractice issues will be less as hospitals will take care of it, like VA system or academics.

Medicine is not what it used to be and will go down in the future. I live in a neighbourhood that doctors can barely afford a nice house here even with their partnership income if they want to work in the city ( large coastal city) and this includes almost all specialties and not only radiology. It is intersting that two of our neighbors are family doctor and OB working a few blocks away who bought their property right out of training with their first job income 20 years ago and paid off the mortgage in 15 years. Both agree that they can not afford even a much smaller property with their current income.

 

[MCAT guy]

Except with a large debt load and malpractice threats.

Live frugral, pay off your debt as you can, and hope for the best.

What is a worst case scenario for annual income later in radiology? Will these cuts be larger than in other specialties?