By Ryan Hakimi, DO, MS, NVS, RPNI, CPB, FNCS
This series will be a running feature highlighting billing, coding, practice management, and other business aspects of neurocritical care.
Physician compensation in academic and hospital-based employment models has historically involved a base salary and some sort of incentive program. The structure and extent of these incentive programs have varied greatly amongst organizations ranging from incentives based on the individual’s financial productivity to incentives based on the department’s or system’s performance.
According to the AMA’s Physician Benchmark Practice Survey, more than half of physicians are now paid in part based on some incentive program (1,2). As organizations look to shift risk from the organization to the individual physician, while focusing on organizational performance (as judged by quality metrics), physician incentive programs are being created that target multiple facets of organizational performance, not just work relative value unit (wRVU) productivity. This is in part due to the fact that physician productivity, as measured solely by wRVU, may not be aligned with the organization’s financial productivity. For example, a physician who puts a central line and arterial line in every intubated ICU patient may have very high wRVU productivity, but the collateral damage from one CLABSI may cost the organization upwards of $100,000 due to other complications, increased length of stay, and in-hospital mortality, not to mention the impact on the hospital’s Star Rating.
Concurrently, CMS has prioritized hospital quality metrics such as rates of CLABSI, CAUTI, pressure ulcers, ventilator associated pneumonia, and so on. Initially, to improve quality, organizations focused on team-member education and mitigation strategies. These mitigation strategies have included improved urinary catheter insertion kits (which included povidone-iodine and sterile gloves), chlorhexidine impregnated central line dressing kits, specialty beds for immobilized patients, subglottic suction catheters for intubated patients, etc. These measures have greatly improved individual hospital’s quality data, but have not always impacted physician’s daily clinical practice, behaviors, and preferences.
Similarly, The Joint Commission (TJC) has created a number of quality measures related to stroke care at Comprehensive Stroke Centers (CSCs). These are known as STKs and are focused on matters such as timely administration of IV thrombolytic therapy and prevention of venous thromboembolism.
Therefore, organizations are beginning to tie physician incentive programs to rates of the various hospital quality metrics. However, given that medicine today is practiced in a team-based environment, how can a given quality metric such as CAUTI rate be attributed to a given physician? Should the infection be attributed to the ordering physician, the physician on the day the culture was drawn, the physician on the day the culture resulted, or the discharging physician?
To address this issue, some organizations have begun with the unit leader, such as the medical director, citing this individual as the ultimate responsible party for the oversite of activities within her/his unit. However, this model of risk attribution is limited by the fact that some ICUs do not operate in a closed model, which allows for heterogeneity of patient population, treatment teams, and physician preferences. Furthermore, most closed model neurocritical care units do allow for patients to be admitted to both Neurosurgery and Neurocritical Care. Therefore, from a practical standpoint, when a patient is admitted to a neurosurgeon who prefers to keep a Foley catheter in the patient for strict I&O monitoring, it is counterproductive for the neurocritical care consultant to discontinue the surgeon’s order as this behavior disrupts team dynamics.
At a recent TJC evaluation, the surveyors shared that they feel that tying physician compensation to stroke metrics is a best practice at CSCs as it aligns best patient care, such as compliance with STK-1 (initiation of VTE prophylaxis within 48 hours for all stroke patients) and STK-5 (administration of an antithrombotic agent to an ischemic stroke patient by the end of day 2), with the physician’s incentive-based compensation. Given the fact that the metric is based on the initial care of the patient, it can be tied to the admitting physician. They also cited that although most Neuro ICUs function in a team-based environment, the ultimate responsibility lies with the attending physician, so that when physicians were financially incentivized they were more likely to ensure that the patient got the appropriate VTE prophylaxis or antithrombotic in a timely fashion.
This example of aligned physician incentives and organizational performance is thought to be the future direction of all physician-based incentive plans. A departure from wRVU-based neurocritical care compensation is appropriate when controlling for the physician’s time on service and ensuring their compliance with appropriate documentation and billing. In other words, if a physician staffs, documents, and bills appropriately on every patient in the Neuro ICU during their time on service, the actual wRVUs are not under their control. This quality-based model also eliminates the financial enticement of unnecessary procedures, which is ultimately in patients’ best interest. All neurocritical care physicians should familiarize themselves with the time-specific definitions of hospital and stroke center quality metrics to provide the best care and to best prepare themselves for future compensation models.