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Top 10 Quality Issues for 2013

 |  By cclark@healthleadersmedia.com  
   January 07, 2013

Quality officials should see this year as among the most interesting, albeit nerve-racking, for acute care hospitals and doctors as major provisions move closer toward official policy under the Patient Protection and Affordable Care Act.  

It's impossible to know or predict them all. But these few, at the very least, will send many hospital and physician leaders reaching for their Pepcid.

For all these thought-provoking issues, there are hopes for greater efficiency, safety, transparency and overall quality of care. But hospital officials should not be blamed if they worry about unintended consequences, and whether they have the resources to manage each and every program.

While some of the policies won't impact payment or quality reporting requirements until FY 2015, performance periods on which hospitals will be judged may begin much sooner. The clock is ticking.

1. Cracking HACs
Section 2008 of the Patient Protection and Affordable Care Act says that payments for the care of Medicare patients discharged as of Oct. 1, 2014, will be reduced based on each hospital's track record of causing or failing to prevent hospital-acquired conditions (HACs) to their patients.

Hospitals will be divided into performance groups, depending on the acuity of their patient mix. Those in the highest quartile of performance, which in this case means those that had the worst number of HACs, will be penalized 1% of their Medicare base DRG rate.

It remains unclear which hospital-acquired conditions the Centers for Medicare & Medicaid Services will include in the list, or during what time period hospitals will be judged. But it may be assumed that performance during all or a portion of 2013 and 2014 could figure in the equation.

These conditions listed on Hospital Compare are obvious candidates:

  • Objects accidentally left in the body after surgery
  • Air bubble in the bloodstream
  • Mismatched blood types
  • Severe pressure sores, usually defined as those classified as Stage III or IV.
  • Falls and injuries in the hospital
  • Blood infection from a catheter in a large vein
  • Infection from a urinary catheter
  • Signs of uncontrolled blood sugar

As of 2008, federal regulation prohibits additional care necessitated by any of those events from being reimbursed when they occur in a Medicare patient. But look for providers to be penalized when they occur in Medicaid patients as well.

Federal officials will send each hospital an updated "confidential report" regarding the number of hospital acquired conditions they had during the performance period.

2. More readmission penalty conditions and exclusions
The PPACA specifies that effective Oct. 1, 2014, penalties for higher rates of 30-day readmissions may apply to four additional conditions that brought the patient to the hospital the first time.

So instead of penalties just for those hospitals with higher rates of 30-day readmissions among patients initially treated for congestive heart failure, pneumonia and heart attack, penalties may extend for patients admitted for a coronary artery bypass graft procedure, placement of a stent, vascular surgery, or care for chronic obstructive pulmonary disease. Eventually, readmissions for hip and knee replacement procedures will be included.

Hospital insiders say they expect federal officials to telegraph these rules with the rollout of the inpatient prospective payment system rule in April.

Much of how the proposed rule is written depends on acceptance and endorsement of such measures by the National Quality Forum, which has already rolled out two endorsements for all-cause readmissions.

Nancy Foster, vice president for the American Hospital Association, says her group is still fighting for a risk adjustment mechanism that takes into consideration a patient's socioeconomic status.

Officials for some hospitals that serve poorer populations and have higher 30-day readmissions believe they have a much tougher problem, the solution for which is less within their control, and are therefore unfairly penalized.

However, one issue may have been partially solved, says Foster. That is the exclusion of certain diagnostic categories from the readmission algorithm. For example, those readmissions that were planned or expected, or readmissions that could not have had anything to do with the quality of care during the index admission, would not be counted.

A patient who is treated in a hospital for congestive heart failure, but who is readmitted for cancer surgery within 30 days, is now counted as a readmission, but shouldn't be, Foster says.

3. Health insurance exchanges must be accredited
The Affordable Care Act requires that all health insurance plans that operate within state or federal health insurance exchanges starting in 2014 be accredited.

That means they have to meet an expansive array of clinical quality measures such as those defined by HEDIS (the Healthcare Effectiveness Data and Information Set), and the doctors they contract with must measure up with high patient experience scores.

Physician networks must include a certain mix of physician generalists and specialists who are confirmed to be accepting new patients, with reasonable wait times for appointments, and within certain geographic areas. They must have certain quality improvement strategies that work to reduce disparities in healthcare.

This generally has not been a problem for states that already require health plans and their insurance products to be accredited in order for their sales to be legal in those states. However several states, such as Montana, Indiana, and Wyoming, don't require accreditation. In some states there has been market domination, so there hasn't been much push to accredit these health plans since consumers don't have much choice.

CMS in November designated the National Committee on Quality Assurance and URAC as the two organizations charged with accrediting all plans offered under state or federal exchanges.

They're going to have an enormous job ahead of them to get all these unaccredited plans approved before Oct. 1, especially in states that don't require accreditation. Many plans will probably seek extensions until next April, NCQA officials say.

That may mean some patients who join exchanges will have to choose plans won't be accredited, at least until some time in 2014. Here's hoping they make the right choices.

4. Compounding conundrum
With 39 people dead and 656 patients sickened so far from meningitis due to fungus-infected steroid injections supplied by the New England Compounding Center in Framingham, MA, hospitals and physicians that have relied on compounding sources should be giving their supply chain a very tough look.

In addition to double-checking the credentials and safety ratings of their sources, the Centers for Disease Control and Prevention in December advised clinicians to be on the lookout for patients with any symptoms near the site of their injection.

5. Patient experience survey expanding
Don't look now, but CMS is proposing to add five questions to its 27- Hospital Consumer Assessment of Healthcare Providers and Systems survey.

Three are designed to get a better idea whether hospitals are giving patients appropriate help as they're discharged home or to another facility.

They are:

  1. During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my healthcare needs would be when I left.
  2. When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.
  3. When I left the hospital, I clearly understood the purpose for taking each of my medications.

Two other questions are intended to determine the patient's mental status and urgency in seeking care.

  • During this hospital stay, were you admitted to this hospital through the Emergency Room?
  • In general, how would you rate your overall mental or emotional health?

These questions for now are being added just to the inpatient quality reporting lineup, and not to be used for evaluating whether hospitals receive value based purchasing incentive payments. That may be just a matter of time.

6. Quality scorecards
Look for more flare-ups and controversy when the Leapfrog Group, Consumer Reports, U.S. News & World Report, and HealthGrades again issue report cards and rankings of various aspects of hospital and physician care.

Many hospitals and their trade organizations predictably will complain that these review systems are biased, contradictory, and confusing to patients who are trying to choose where to have an elective procedure.

One effort to make sense of it all is underway by Premier, Inc., a healthcare performance improvement alliance with 2,700 hospital participants. "Right now, we're doing a good job of measuring various individual components of safety and quality in acute care," says Richard Bankowitz, MD, Premier's chief medical officer.

"But hospitals want to get a sense of their overall safety within the entire organization," and the public wants to understand that too."

Look for Premier to release a list of more than 130 PIC measures, or potential inpatient complications of patient care, conditions that weren't there when the patient came through the door, all rolled up in one easy-to-understand score.

7. Hospital-acquired blood clots
Look for more discussion about measuring how well hospitals screen their patients and administer preventive drugs to prevent blood clots, an event that until recently most hospital intensive care specialists thought were just unavoidable bad outcomes in acute care.

But that is no longer true. Increasingly, hospital medicine researchers say payers are right to demand accountability for hospital venous thromboembolism prevention strategies.

And Medicare now refuses to pay for extra care when a pulmonary embolism or a deep vein thrombosis necessitates extra care in a patient admitted to the hospital for a total hip or knee replacement.

The CDC is pushing for a uniform VTE reporting system similar to that in place for central-line bloodstream infections through the National Healthcare Safety Network.

8. Sepsis alerts in the emergency department
Look for CMS to roll out yet another quality checklist for doctors and nurses in the emergency room that will look for symptoms of sepsis, the body's response to infections in the blood that is a frequent cause of preventable hospital death. Symptoms are often overlooked until it's too late.

Premier's Bankowitz says the federal quality initiative is an attempt to get emergency teams to look for evidence of hydration, serum lactate levels, antibiotic administration, and culture sampling so they function more rapidly to prevent progression.

"A lot of the time the diagnosis is missed. Sepsis isn't considered, because the symptoms can be subtle, especially in patients with a fever or mental status changes."

9. Squeezing waste
It's 2014. And let's say you're a poorly performing hospital on every measure now being scored under incentives and penalties written into the Affordable Care Act.

Unacceptable 30-day readmissions, lousy patient experience scores, poor compliance with core measures, high 30-day mortality, and higher numbers of hospital acquired conditions: Your hospital hit the jackpot.

According to a chart presented at a recent Institute for Healthcare Improvement forum, a sample 500-bed hospital that is a poor performer in every respect could see reductions in payments as high as 2.8% starting this year, falling to 9.1% in 2015, 12.2% in 2015, 14.1% in 2016, 15.6% in 2017, 17% in 2018 and 18% in 2019. Repeat for emphasis: 18% by 2019.

That includes market basket, productivity cuts, geographic variation cuts and wage index cuts, as well as disproportionate share reductions for certain hospitals that receive those funds.

No matter how you figure it, there's enormous incentive for hospitals to reduce variation to get costs lower and improve quality to avoid extra charges eroding revenue from each patient DRG.

10. Blood management
Expect there to be more discussion within acute care settings about how blood transfusions in certain patients who are not actively bleeding may not only be unnecessary, but may be resulting in avoidable adverse reactions, longer lengths of stay, and poorer long-term patient outcomes.

Hospital leaders looking to tighten the belt may not have thought about the cost of blood as a significant part of their budget. But now, more are factoring in extended lengths of stay for patients—about 1% of whom may have an adverse reactions to that transfused blood—and hospital lab processing costs that can elevate a red cell unit's price tag from $210 to $1,000.

A several-year program run by Premier for 464 participating hospitals found variation in blood management practices that was astonishingly wide.

If all the hospitals in the group changed transfusion procedures to those adopted by those hospitals that used the least amount of blood, some 802,000 units of blood would not have been used, and these 464 hospitals would have saved $165 million per year.

See Also:

Top 12 Healthcare Quality Concerns in 2012

Top 10 Healthcare Quality Issues for 2011

Top 10 Issues Facing Healthcare in 2010

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