Proposal for Physicians to Share Reward and Punishment for Care

By Chuck Dinerstein, MD, MBA — May 10, 2017
The American College of Surgeons recently announced submissions of their plan for attribution of care and physician payment to the Health and Human Services Department’s Planning and Evaluation Office of Health Policy. Let's discuss their approach to attribution, since surgery is a team activity.

I have written before about attributing care to individual physicians who lead a ‘team’ rather than to all of the team members. CMS continues to ready the rollout of bundled care packages for acute myocardial infarctions and for coronary artery bypass surgery (CABG) which gives a unified payment to the hospital or another intermediary to split up among the various team members, surgeons, anesthesiologist, and consultants. Those teams with good outcomes and costs below the benchmark are rewarded, those with costs above the benchmark or with adverse outcomes are penalized. But as I alluded to in my original article, the devil is in the details of the split of rewards and punishment.

Last week, the American College of Surgeons announced submissions of their plan for attribution of care and physician payment to the Health and Human Services Department’s Planning and Evaluation Office of Health Policy. As with any policy document, it is long and technical, and I will spare you most of the details. But I want to share their approach to attribution. Surgery is a team activity. Here is a graph showing the number of physicians involved in colectomy, a procedure where part of the large intestine is removed. Typically three to ten physicians are involved in care for this one procedure.


They go on to define five different roles for physicians in providing care and then attribute percentages of care to those roles in three different clinical settings or in the parlance of HHS, episodes. Procedural episodes refer to elective admissions for procedures, surgery, endoscopy, angioplasty. Acute conditions are episodes of acute medical problems like pneumonia, or myocardial infarction; they also include exacerbations of chronic conditions, for example, care for a patient with a ‘flare-up’ in their asthma. Chronic conditions include care associated with long-term medical problems like congestive heart failure or diabetes. Here is the breakout in services:

So why is this important?

  • It defines primary care roles as well as roles for specialists who provide longitudinal care for chronic conditions.
  • It defines roles for supporting physicians and other providers.
  • The definitions of care episodes cover approximately 75% of all physician charges for Medicare.
  • With defined attributions, reward and penalty are apportioned to the actual care team rather than simply to its leader.

It is this last component that is the most beneficial and at the same time disruptive. It is a fairer system than making all rewards or penalties to one individual who in fact may not be the actual physician providing the most critical portions of care. But it means that the doctor who bears the greatest attribution can construct their care team with both economic efficiency and outcome in mind. The role of supporting provider and episodic provider is often given to friends or business relations without as much concern about the outcome; after all, when thinking of referrals, friendship, affability, and availability may trump ability. But when your income is tied to your teammates then perhaps ability will become the crucial consideration.





Chuck Dinerstein, MD, MBA

Director of Medicine

Dr. Charles Dinerstein, M.D., MBA, FACS is Director of Medicine at the American Council on Science and Health. He has over 25 years of experience as a vascular surgeon.

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