Whoever Feeds the Adjuster Controls What It Finds

The post: Dr. Primus weighed the Patients First Act (H.R. 9693): she credits its inflation-linked Medicare updates and primary care payment pilot, but asks how well the pilot's risk adjustment will work, who can participate, and what happens when the pilot ends.

Read Dr. Sally Primus's original post on LinkedIn →

My comment:

Your risk-adjustment question is the one I'd underline, and I'll answer it from the wrong side of it.

Any payment model that pays on a description instead of an examination will produce better descriptions. Not better care. That's not a prediction — it's just what happens when the people writing the documentation are the ones paid by it.

I ran clinics and labs across Michigan and Ohio under fee-for-service. I wasn't a doctor. I owned the protocol, the physicians, the lab, and the billing, which meant I owned every input the system had. Nothing downstream could see past what I chose to write. I pleaded guilty to $150 million, served eight and a half years, and still owe a balance of $51 million in restitution.

Moving to a monthly per-patient payment doesn't remove that problem. It relocates it. Under fee-for-service I was paid for volume of procedures. Under capitation, the money follows how sick the panel looks on paper — and someone decides what gets written down.

Worth noting the bill limits this to physician-owned practices. That's aimed squarely at structures like the one I built (MSO), a reasonable instinct.

I'd just add: whoever controls what the adjuster is fed controls what the adjuster finds. I know because I controlled them.

Originally posted as a comment on LinkedIn.