With healthcare costs projected to climb to 20 percent of the U.S. gross domestic product by 2020, controlling spending has become a national imperative. Although physicians influence at least 60 percent of healthcare costs, there is a dramatic disconnect between physicians’ fiscal responsibility and their knowledge of healthcare resource management, according to a viewpoint published March 20 in the Journal of the American Medical Association.
Formal education in program integrity is an essential component of medical professionalism, according to Shantanu Agrawal, MD, from the Centers for Medicare and Medicaid Services in Baltimore, and colleagues. Program integrity—which refers to losses due to inefficiencies, inappropriate payments or exploitation—includes waste, abuse and fraud.
Although few physicians are guilty of abuse and fraud, nearly all contribute to waste, which may account for 30 percent of healthcare costs, according to Agrawal et al.
The authors referred to the common scenario of discordance between billing and diagnoses, with documentation often failing to support the magnitude of billing and reimbursement. In 2011, the overall Medicare fee-for-service error rate approached nearly $30 billion. The main contributors? Insufficient documentation, lack of medical necessity and coding errors.
Agrawal and colleagues also referred to perverse incentives in the fee-for-service payment structure, including those related to physician ownership of imaging equipment. “Studies have evaluated the use of various discretionary diagnostics and found an association between physician ownership of imaging equipment and use of testing,” the authors wrote.
Another challenge is upcoding and code creep. The annual tally for coding increases is 1 to 2 percent, translating into millions of dollars in additional spending.
The authors skirted the topic of fraud and abuse, and turned to the more common issue of conflicts between patient care and payer policy. “A significant portion of physicians may be willing to deceive public and private payers when deception serves patient interests and meets a moral care obligation,” wrote Agrawal and colleagues.
The solution, according to the authors, is greater physician education and awareness. However, existing opportunities for program integrity education are sparse. The authors outlined three pathways to remedy the disconnect. These are:
- Graduate medical education—adding specialty-specific training in program integrity to residency and fellowship training programs.
- Licensure—Requiring practicing physicians to complete CME credits in program integrity during licensure renewal.
- Specialty certification—Including demonstration of program integrity knowledge in maintenance of certification requirements.
Agrawal concluded by noting that pending payment reform will impact incentives but does not supplant the need for physician awareness.