Every practitioner is being positioned on a grid in relation to the cost of care as described, and their quality score which is usually a score obtained from MIPS quality reporting. The ideal position on the grid is the top right corner. To CMS, that person delivers high quality care at low cost. Unfortunately, we do not report quality on the same patients who are represented in the cost of care calculations, nor do the quality measures we report provide insight into the care provided by that practitioner.
Below is a scatterplot of all the family medicine physicians in the country. There are quite a few in the lower left quadrant that represents low quality and high cost. I in the lower right quadrant which represents high quality and high cost. I’m down there because the Medicare Spending Per Beneficiary (MSPB) of my patients is higher than those of other family practice doctors (the cost component). That is because they are MUCH sicker, based on the fact my HCC score is TWICE that of the average physician in the country. The severity of my patients is typical for a nephrologist, as are their costs. I may have a maximized my quality score by using the US Wound Registry (USWR) for quality reporting, but the best cost score cannot compensate for having a much greater MSPB if the comparison group are patients seen by family practice doctors.
The real problem is that I am being compared to the wrong group! I shouldn’t be in the group with the family practice doctors! How do I get compared to a group of practitioners who see similar patients to me? It’s based on specialty code, so I need a different specialty. Undersea and Hyperbaric Medicine is a sub-specialty and has its own taxonomy code. That wasn’t available for me to use when this report was created by CMS – but now hyperbaric medicine has a taxonomy! (see my past blog on how to change your taxonomy code). I might be in the TOP right quadrant that represents high quality, LOW cost care if I were being compared to other doctors who practice wound care and hyperbaric medicine.
Key Point: If all the wound care and hyperbaric medicine practitioners changed their taxonomy to identify themselves as undersea and hyperbaric medicine doctors, then the per capita costs attributed to those doctors would make more sense.
Why does it matter if I am in the lower right quadrant instead of the upper right quadrant of the cost and quality grid? Why should I care? I care because it impacts how much I am paid for my services. Below is a table that shows how the value adjustment factor works. A practitioner in the high quality, low cost tier can get an additional 2% of Medicare Part B payments for delivering “value.” When I contract my services with private payers, that “value” adjustment can be even higher, or worse, if I might not even be allowed to see patients with some private insurance because I am in a low value tier.
Physician Payment “Value” Adjustment Factor based on the Cost and Quality Tier