Do you know you are being scored?

The imperative of practicing exceptional medicine

For any physician, practicing exceptional medicine is a critical consideration. It is widely acknowledged that physicians should deliver value, which is defined as the ratio of outcomes to cost. However, the true value of a physician varies depending on the stakeholder involved (Table 1). This article will focus on the payer and provide guidance on how physicians can enhance their value to this particular group.

Understanding costs in contract negotiations

As maternal-fetal medicine specialists with more than 3 decades of experience in contract negotiations and practice management, we have learned that both our practices and our individual cost structures are crucial for determining contracted rates. More sophisticated plans will have detailed data on the costs associated with our services for each patient broken down by pregnancy year and office visit. It is vital to consider these data during negotiations. If such data are not presented, you must request them for your practice and team. Some plans may already have this information, whereas others may not. With a longstanding relationship with your plan or medical director, you can request comprehensive data for the entire plan and benchmark your practice against others.

Calculating your impact on costs

To understand the cost impact, consider the following basic formula:

• Overall patient cost/number of overall patients=A (average cost per patient overall)
• Group cost/number of patients seen by your group=B (average cost of patient seen by your group)
• A–B=difference in cost per patient overall vs your group per patient

This calculation can be applied to pregnancies or patients overall. It is important to note that these data are not risk adjusted, but payers may use this for negotiation, and if advantageous, you may want to as well. Similarly, if your group’s cost is higher, you may want to evaluate where cost savings in care could be applied without worsening outcomes or, ideally, while improving outcomes.

Unfortunately, most payer negotiators aim to establish contracted rates based solely on Medicare rates. Your group or organization does not want to negotiate based solely on this slippery slope. If you are committed to being recognized as a value provider, obtaining your relative cost per patient is crucial. This allows contracting based on overall costs, not just Medicare rates. For instance, if your services cost $100 less per patient, sharing these savings with the payer—assuming your outcomes are comparable to competitors—can be beneficial.

Metrics beyond costs: Improving your scores, another important payer value

Payers often use Healthcare Effectiveness Data and Information Set (HEDIS) scores for quality, particularly in Medicaid-based plans. Are you aware of your HEDIS scores? If not, consider requesting them from your payer. Understanding the metrics you are judged by is essential for improvement.

For example, UnitedHealthcare¹ and Molina Healthcare² offer online reference guides that outline the metrics used in their evaluations. These guides can be instrumental in helping you understand and improve your scores.

Quality scoring systems such as HEDIS not only provide a standardized framework for evaluating care but also serve as a catalyst for continuous improvement. To aid in performance and documentation, consider integrating prompts within your electronic medical record (EMR) system to capture these measures. Although HEDIS scores are a narrow measure of overall care quality, they are quantifiable and therefore significant in your performance assessment.

Physicians can leverage these data to identify gaps in care delivery, optimize clinical processes, and ultimately elevate patient outcomes. By actively engaging in quality improvement initiatives and integrating patient feedback into practice adjustments, physicians can directly influence their scores and the health of their patient community.

Alternative scoring systems

In addition to traditional methods, alternative scoring systems such as Embold Health use HEDIS scores along with other metrics—including ultrasounds per patient, screening rates for genital herpes, episiotomy rates, and ultrasound usage in patients with low risk—to track patient data. Embold Health harnesses a robust data set of closed claims to pinpoint high-quality, cost-effective health care providers within local communities. These data empower both patients and providers by enhancing the quality of care, possibly reducing unnecessary medical procedures, and aiming for delivery of cost savings to both employers and members. Employers and payers can leverage this information to refine quality measures and achieve financial efficiencies. Providers may ask for access to these reports online. Some organizations, such as the US Women’s Health Alliance, provide these data at no cost to their members.

Coding: A critical aspect of quality measures

Providers often feel detached from scoring systems; however, the way providers code significantly influences their data. Coding is not merely for billing; it is a critical aspect of quality measurement and must be executed accurately to reflect your capabilities. For example, following are the data in Embold that make a delivery low-risk (Table 2):

Table 2. Low-risk criteria

Many physicians focus on coding primarily for immediate reimbursement rather than considering its implications for quality scoring systems. However, in the broader context, where quality is assessed based on coding accuracy and contracting relies on these quality scores, strategic coding becomes crucial for achieving both short-term and long-term objectives.

A thorough review of your procedure templates is essential, as it can uncover outdated practices that negatively affect quality scores. For instance, a physician in our group who had not performed an episiotomy in years was found to have an anomalously high episiotomy rate. This discrepancy was traced back to a decade-long note in the delivery templates that had not been updated and at times not edited, leading to persistent incorrect coding. This example underscores the importance of regular reviews and updates to clinical documentation to ensure accuracy and relevance, thereby enhancing the integrity of quality measurements and the effectiveness of health care delivery.

Navigating costs with payers

It is essential to approach prenatal genetic testing with vigilance. The out-of-pocket costs communicated to patients by genetic screening companies often do not represent the total amount billed to payers, which can be substantially higher. Additionally, ultrasonography is frequently overused, leading to increased scrutiny from payers. To ensure medical necessity and enhance the likelihood of reimbursement, verify that there are clear clinical indications for these procedures.³

Proper coding is crucial not only for accurate billing but also for aligning patient care with payer requirements. Accurate coding helps categorize patients into appropriate risk levels, facilitating utilization reviews by payers. This alignment between clinical necessity and billing ensures that scoring systems accurately reflect patient needs, thereby supporting optimal health care delivery and cost management.

Conclusion: Awareness and proactivity in contracting

Being aware that you are being monitored and scored is crucial. It affects your ability to contract effectively and improve your quality scores. By taking control of coding, setting up your EMR to capture essential quality measures, and engaging with insurers about costs, you can demonstrate your value to payers and enhance care quality.

References

1. UnitedHealthcare Quality Reference Guide. UnitedHealthcare. 2024. Accessed July 10, 2024. https://www.uhcprovider.com/content/dam/provider/docs/public/reports/path/2024-PATH-Reference-Guide.pdf
2. 2024 Medicaid HEDIS reference sheet for providers. Molina Healthcare. 2024. Accessed July 10, 2024. https://www.molinahealthcare.com/-/media/Molina/PublicWebsite/PDF/Providers/fl/medicaid/HEDIS-2024-Medicaid-Tip-Sheets-UPDATED_R.pdf
3. Ultrasound for pregnancy. Aetna. Updated April 11, 2024. Accessed July 10, 2024. https://www.aetna.com/cpb/medical/data/100_199/0199.html