"Everything You Know Is Wrong!" the title of an album by the comic troupe Firesign Theatre, came to mind this week as I reviewed the state of chaos that stymies progress in healthcare quality.
The Senate may not confirm Don Berwick as administrator for the Centers for Medicare and Medicaid Services. Anticipated CMS regulations governing accountable care organizations are held up, reportedly because the Federal Trade Commission sees a lethal anti-trust flaw. And the entire Affordable Care Act has been declared unconstitutional by a Florida court, although the Obama administration is asking for a speedy decision to its appeal.
If all these obstructions aren't enough to befuddle providers, I wandered into the comments section of CMS' regulations.gov yesterday to find nearly 300 postings on the agency's proposed regulations governing Hospital Inpatient Value Based Purchasing (VBP) penalties (the deadline for filing comments was 11:59 p.m. Tuesday).
I took a sample of 32 comments and found vehement objections to various aspects of the formula that directs how hospitals will soon be paid. I wondered, how did the process get this far along with so many major players still finding so much to oppose?
Perhaps the most detailed dissection of the regulations' perceived unfairness came from American Hospital Association executive vice president Rick Pollack, who wrote a nearly 10,000-word letter with strong protests on nearly every one of its 20 pages.
The AHA and many others say major parts of the regulations lack validity, and may even pose unnecessary risk to patients, in the following ways:
1. Many of the clinical processes of care measures in the formula have already been "topped out" meaning hospitals are now scoring 98%, 99% or 100%, such as, in prescribing aspirin to a heart attack patient at discharge. A hospital scoring 98% would receive one point for achievement for scoring at the threshold, while a hospital at 99% would receive 10 points for this at the benchmark, with no reward for a hospital scoring in between.
"A hospital that consistently performs at a high level of performance, (>=95%) should not be penalized under the current methodology when the achievement thresholds are tightly clustered between 95% and 98%," wrote Bobbie James, outcomes analyst for Intermountain Healthcare in Salt Lake City.
Said Pollack: "Asking hospitals to strive for 100 percent compliance on the measures promotes overuse; that is, the provision of treatment to some patients who may not benefit from it. This is a waste of resources and poses some degree of unnecessary risk to the welfare of the patient."
2. In 2014, the VBP formula will add to the formula eight measures of hospital-acquired conditions (HAC), such as letting patients develop pressure ulcers or forgetting to remove a surgical sponge. But these are the same ones that are included in the current inpatient prospective payment system HAC policy and identical to measures in another section of the ACA that separately penalizes hospitals with high rates these mistakes. "The AHA strongly opposes the inclusion of HAC measures in both the VBP program and the HAC policy because of the opportunity for hospitals to be penalized twice on the same measures,” wrote Pollack.
3. In 2014, hospitals will be penalized if their 30-day mortality rates for patients with heart attack, heart failure or pneumonia exceed expectations. But several commented they're worried the current risk adjustment methodologies for these measures is frail. Also, patients in the hospital to receive palliative end of life care are not excluded. "Hospitals that run large palliative care programs will have higher mortality rates," and penalizing them is inappropriate, Pollack wrote.
4. A huge issue in many letters deals with CMS' proposal to weight patient experience survey scores as 30% of the total. "Given the potential inadequacies of the risk adjustment, CMS should reduce the weight of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey to at most 20% and conduct further research," said Premier Healthcare Alliance.
Wrote Anne Dykes of Monroe County Hospital, in Mobile, AL, "We do not agree that cleanliness of a hospital and quietness of hospital should be a combined question on HCAHPS."
5. A portion of the formula based on hospital spending per admission penalizes hospitals that care for more patients with chronic conditions, Adventist Health System's chief information officer Brent Snyder worries. "The larger cost issue is a coordination of resources to care for patients over multiple care settings, including the patient's home," he wrote, so VBP efficiency measures should be enforced through ACOs as well.
6. The provision that excludes hospitals that have been hit with an immediate jeopardy citation from participating in incentive payments under these rules is unfair because state programs differ dramatically in their aggressiveness in filing these penalties, several commenters complained.
"The current survey process in declaring an immediate jeopardy is extremely inconsistent from state to state, which could very well result in systematic biases between areas in the number of hospitals that receive citations and are excluded from the VBP program, wrote Pollack. (More on this in a future column.)
Premier Health Alliance wants CMS to not penalize hospitals that remediate an immediate jeopardy before their survey.
7. There are big problems with the three categories of measures due to kick in for 2014: measures for mortality, the Agency for Healthcare Research and Quality metrics such as having patients with post-operative respiratory failure, and hospital acquired conditions, the AHA's Pollack says. "The agency provides virtually no detail on how it proposes to score" hospitals performance," he says.
8. The proposed minimum of 10 cases a hospital must have to be included for certain metrics is too low, and is inconsistent with current requirements on Hospital Compare, which calls for at least 25, several organizations complained. "With less than that number the site (Hospital Compare) states that CMS cannot 'be sure how well a hospital is performing,' " Pollack wrote.
9. The regulations would allow CMS to have access to quality improvement organization information, which Pollack says would "strip many of the confidentiality safeguards and go against Congress' original intent in putting the confidentiality provisions in place."
Wrote Stacie Neff of Clallam County Hospital District in Washington State, "Before CMS gives/sells CMS performance data to outside vendors/researchers, we would want rigorous assurances and safeguards to ensure our patient’s privacy and confidentiality."
10. Safety net hospitals can't be judged by the same standards as the typical American hospital, Ellen Kugler, executive director of the National Association of Urban Hospitals, wrote . The VBP regulations assume that in an emergency room, "physicians can make a swift, clear, and specific diagnosis." This is challenging when patients in low-income, urban safety net hospitals are fundamentally sicker, with years of neglect and with co-conditions that mask or are more prominent than an underlying condition associated with a specific quality measure, she wrote.
There were a lot more objections in these letters, but more on that in later columns.
Though many of the comments on the CMS website were negative, not all were. Here's one from Vivian Lauderdale of Encinitas, CA.
"Dear CMS: I am a grandmother, mother, health technology professional and have had a personal experience with harmful healthcare events. Please record my full support of the proposed rule ... because it can have enormous impact on our healthcare due to the fact that hospitals will only be paid if they are accountable for safety improvement. ...There may be many special interest groups that oppose this rule; however, I believe that the data or measures do not need to be perfect to move the motivations of America's healthcare leaders and caregivers to improving care in this country."
After reading these comments and watching the state of paralysis and disagreement in which healthcare providers seem to find themselves in right now, another favorite line from Firesign's repertoire springs to mind:
"How can you be in two places at once when you're not anywhere at all." In my humble opinion, we should all move forward with healthcare reform and fix problems along the way. As the saying goes, let not the perfect be the enemy of the good.
To read more about what providers and others think about CMS' VBP regs, visit regulations.gov and search "Comments" with the keyword CMS-2011-0003