Category Archives: CMS

It’s a Start

There is a deadly explosion of opioid addiction in the United States. While it is clear that nothing this complex or widespread can have a single cause, it is also clear that American prescribing habits have been a significant contributing factor.

According to the Department of Health and Human Services more than 240 million prescriptions for opioids were written in 2014, and it is well established that prescription oral analgesics are the principal gateway for heroin and other injection narcotics.

It is also true that use of narcotic analgesics is much higher in the United States than in other countries. Here again, the difference between the US and the rest of the world probably has multiple causes, including pharmaceutical marketing, and the easy availability of drugs. Recently, CMS implicitly acknowledged another cause: the creation of patient expectations around pain control, and the subsequent pressure that has had on US physicians’ prescribing habits.

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Who’s in Charge Here?

I spent a couple of hours today discussing a topic that has become increasingly important in the world in which we live, and which would have completely mystified an earlier generation of physicians. The subject was “attribution.” Simply put, how should one decide which patients “belong” to which doctors? On a more technical level, what algorithms should be employed to connect patients, or episodes of care for those patients, or specific quality measures pertaining to those patients, to particular physicians?

Here’s why this is a hot topic. CMS is moving rapidly to alternative payment models. Medicaid is transitioning to a capitated system. Commercial payers are entering into “risk” arrangements with providers. All around us, fee for service is losing sway and is being replaced by a spectrum of new ways to pay for care. In the “old world” of fee for service, whoever provided the service got the fee. There was no mystery about how the dollars should flow. In the “new world” all that changes. In many instances, payments are linked to quality measures. So, for example, physician groups or integrated health systems may be subject to penalties or earn bonuses depending on how “their” patients do. Too many readmissions? Penalty. Excellent blood pressure control? Bonus. Simple enough in theory but complicated in practice.
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