The Quality Metric That Rewards the Wrong Thing
You lead a 6-site ambulatory network. A payer introduces a value-based contract that pays a bonus if the percentage of diabetic patients with a completed annual retinal exam exceeds 70%. Baseline is 54%. The bonus is worth roughly $400,000, which the CFO has already built into next year's budget. You learn that one site has been scheduling retinal exams for patients who are not due, ordering repeat exams within the same year, and counting exams done at outside ophthalmologists without documentation. The compliance officer flags this as potential upcoding. Site leaders say they were only 'being aggressive about the metric.' The contract's measurement period ends in 90 days.
1. How should you respond to the compliance concern while still pursuing the legitimate quality goal?
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Separate the legitimate quality aim from the gaming behavior, and act on both:
- Stop the improper practices immediately. Repeat exams within the measurement year and exams on patients not due are not clinically indicated and may constitute misrepresentation. Direct the site to cease and require documentation of medical necessity.
- Define the counting rules in writing: which exams count (in-network vs. outside), how outside documentation must be obtained, and who is eligible. Ambiguity in the contract likely enabled the drift; clarify it with the payer if needed.
- Audit before the period closes. Pull a sample of claimed exams and verify indication and documentation. If errors are found, self-correct the data and consider proactive disclosure to the payer - voluntary correction is far more defensible than being caught.
- Address culture: 'being aggressive about the metric' is a warning sign. Reframe the goal as closing genuine care gaps (patients truly overdue), not maximizing the numerator.
- Protect the financial plan: tell the CFO the $400k is at risk and model a realistic trajectory from honest gap-closing.
The key judgment: you can pursue the bonus ethically by finding genuinely overdue patients, but you cannot let the metric define what counts as appropriate care.
2. Ninety days remain. What is a realistic, defensible plan to improve the true rate without cutting corners?
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A defensible 90-day plan focuses on identifying truly overdue patients and removing access barriers:
- Registry work: query the EHR for diabetics with no documented exam in the past 12 months. This yields the honest denominator and the real gap.
- Point-of-care capture: many patients seen for other reasons are overdue. Add a retinal exam or referral prompt to diabetes visits; consider an on-site camera or a mobile screening event.
- Outside documentation: build a process to request and upload outside ophthalmology records so legitimate exams count.
- Outreach: targeted calls/texts to overdue patients, with transportation and scheduling help; evening or weekend slots.
- Track leading indicators weekly (overdue list size, completed exams, documentation received) rather than waiting for the final number.
Be explicit that the realistic lift may fall short of 70%, and that hitting the number by improper means is not an option. Present a range of outcomes to leadership so the budget conversation is honest. The judgment being tested is willingness to accept a lower bonus rather than manufacture one.