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Depiction of Total Per Capita Cost (per provider)


After CMS calculates Medicare Spending Per Beneficiary (MSPG), it calculates a practitioner’s Total Per Capita Cost. This is the overall cost of care provided to each of the beneficiaries attributed to a specific doctor. In other words, patients have an episode of care, each episode is attributed to a specific doctor, and all that doctor’s episodes become the Total Per Capita Cost (TPCC).  TPCC is risk adjusted based on the practitioner’s medical specialty.
Key Point: Wound care and hyperbaric medicine practitioners, because of their frequent (sometimes daily) contact with patients, are held accountable for the cost associated with hospitalization. There is a list of conditions used by CMS to calculate Medicare spending (e.g. heart failure). These costs are likely to be attributed to the wound care/hyperbaric practitioner because they bill the plurality of physician visits. The attributed costs are then compared to the aggregate of all the practitioners in that doctor’s same specialty, most of whom do not practice wound care
I hope you followed the way in which wound and hyperbaric medicine practitioners are being held responsible for the cost of hospitalization for co-morbid diseases. CMS decides whether a wound/hyperbaric practitioner’s cost per beneficiary is high or low by comparing the wound/hyperbaric practitioner’s spending to practitioners who do not practice wound care or hyperbaric medicine. What could go wrong?

My Spendthrift Ways

The figure below, taken from my 2018 MIPS report, depicts my Total Per Capita Cost and episode cost. As you can see, my episode cost is $58,000 whereas the average family practice doctor’s is about $16,000. As a wound care practitioner, my costs are much higher than the typical FP. They are so much higher that CMS gave me the worst possible (lowest) score in the cost category of MIPS (3 out of 10). Medicare looked at the price tag of my patients and said, “As a Family physician, she expends far too much of Medicare’s resources. She must be providing unnecessary care.” One of these days, CMS is going to insist that I pay some of that money back and there is a mechanism inside MIPS to enable that.

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