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ACA Turns Two; Has it Improved Quality of Care?

 |  By cclark@healthleadersmedia.com  
   March 22, 2012

Lawmakers clearly put a heavy emphasis on quality of care when they crafted the Patient Protection and Affordable Care Act. The word "quality" appears 563 times.

But is there any evidence this law, which marks its second birthday this week, has improved quality of care?

Sure, it has made healthcare more affordable with reduced cost-sharing and expanded coverage without lifetime caps for millions of people.

And yes, the law's rules are saving consumers $17.7 billion in prescription drug costs, are allowing 45 million women to receive preventive care with no cost-sharing, and are cutting red tape to eliminate $4.5 billion providers would otherwise spend. Each day brings another press release about how the ACA has improved access to care or reduced its cost to consumers.

But do patients today have a better chance they'll get the right care at the right time? Are the odds better that they won't be infected or otherwise injured by hospital teams and doctors in the process?

And are providers now avoiding more readmissions, saving more lives, preventing more harm, and providing patients with a more prompt and pleasant healthcare experience? Or do we have to wait a few more years to see these results?

I'm going with "yes" and "no"—with caveats.

I'm evasive because these matters are complicated and hard data is tough to get. It seemed even more befuddling after I asked a few wise people these questions, including some stalwart ACA boosters.

'A period of confusion'
All of them hedged, saying it's still too early for most of the new rules to have had an impact on quality. Providers are just beginning to figure out where they stand under the threat of penalties for higher rates of 30-day readmissions, hospital- acquired infections, and 30-day mortality, or for lower value-based purchasing process measures and patient experience scores.

The first VBP performance review period for payment that takes effect Oct. 1, 2012, doesn't end until March 31, the end of this month. And the first evaluation period for 30-day mortality rates, to be factored into the VBP formula for incentive payments starting Oct. 1, 2013, doesn't end until June 30, 2012. The first three-year performance period to determine penalties for excess readmissions ended June 30, 2011, but CMS has yet to release final scores. Hospitals are nervous, because they still may not be sure where they stand.

These ACA penalties for hospitals, you'll recall, could eventually total 6% of Medicare DRG payments for a hospital that performs the worst in all categories, a potentially devastating chunk of change for struggling facilities that depend on federal reimbursement for their survival.

"This is a period of confusion and shakeout for hospital leaders as they try and figure out how to be responsive," says Donald Goldmann, MD, an infectious disease practitioner at Children's Hospital Boston, and senior vice president of the Institute for Healthcare Improvement. "I honestly think it would be naive to expect any impact on actual outcomes in this period of time."

Evaluating ACA's effects 'complicated'
On reducing 30-day readmissions, for example, Goldmann says, "I don't think it's reasonable to think that the American hospital system is going to immediately initiate all the improvements and best practices that lead to improvement in readmissions, especially since improvement will require partnership between hospitals and community providers. Hopefully, improvement will accelerate next year as interventions start to take effect."

He adds that "evaluating the effect of the (law) per se is complicated because some of the outcome measures were already improving as a result of previous efforts."

For example, a 2008 law determined that CMS would not pay for care necessitated because of certain preventable hospital-acquired conditions such as falls, medication errors and pressure ulcers. Other quality improvement organization efforts predate the ACA. And certain types of healthcare-associated infections have been dropping for several years, led by early adopters following checklists and with aggressive campaigns from the Centers for Disease Control and Prevention.

CMS could 'do a better job' of communicating
Of course part of the challenge in getting providers to embrace quality in the past has been the fact that for the most part, healthcare consumers don't understand that the healthcare system is far from uniformly good, Blair Childs, vice president for Premier healthcare alliance, a quality improvement organization with 2,400 hospitals, said in an interview.

"Only people that study this understand that there is significant variation in quality. Most people don't have a clue that there's a problem in the system," he says. "So when you try to say things have gotten better, people say, 'Well, that implies they weren't good in the first place.' " Perhaps because of loyalty or disbelief, most people don't want to hear any reason not to trust their hospital.

In an interview this week, Patrick Conway, MD, director and chief medical officer for CMS' Office of Clinical Standards and Quality, the agency that uploads data to the Hospital Compare website, acknowledged that his agency could "do a better job communicating the message" about the ACA's positive impact on quality of care.

For starters, he says, his agency is about to release statistics showing dramatic improvement from the inpatient quality reporting program over the last five years, in which hospitals have been paid for reporting on outcomes and process measures, in exchange for increases in pay. That's not a result of the ACA, of course.

But "if you look at hospital value-based purchasing measures, we're still in the first performance year," Conway says. "I don't know the data yet, but our hypothesis is that if we have a pay for reporting program that sees decreases in mortality and improved performance on those measures, that as we move to VBP, where there's actually payment associated with performance, we'll at least see a similar and we think higher, increase."

Conway says he travels frequently across the country to visit hospitals "and every one I've visited literally has a dashboard of performance measures for VBP and is tracking them monthly, gauging their improvement. ... I'd say from a front line provider's perspective, hospitals are incredibly focused on these measures like experience, mortality, and care coordination. And I think we'll see those benefits bear out."

For example, the PPACA calls for penalties for hospitals with higher rates of hospital-acquired conditions. And though CMS has not proposed those rules as of yet, "people know that HAC payment reductions are coming, and so once again, although the performance period and payment adjustments haven't started I can tell you that hospitals are incredibly focused on reducing their HAC rates now to avoid future payment reductions."

Additionally, the PPACA has enabled numerous other tools to help individual hospitals improve care, such as the $1 billion the feds get to spend for efforts like Partnership for Patients.

But, I asked, does Conway think his mother would receive better and safer care in a hospital today than before the ACA passed?

"Yes," he replies. "Where you have focus and measurement, there's improvement." And, he adds, "my mother is a Medicare beneficiary, so it is a personal question that I think about a lot."

It has been two years since President Obama signed the landmark ACA legislation. Next week it faces its toughest test as its legitimacy is argued before the U.S. Supreme Court. As one policy institute quipped Tuesday "The Affordable Care Act Turns 2...Will It Turn 3?"

So my birthday wish for ACA is that in coming weeks and months, government agencies and provider collaboratives will be much more transparent and forthcoming to answer these questions about PPACA's impact on quality. And in so doing, ACA and the patients affected by it will all grow older, wiser, and of course much, much healthier.

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