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Top Healthcare Quality Issues for 2014, Part 1

 |  By cclark@healthleadersmedia.com  
   January 06, 2014

The pressure to reduce readmissions and preserve reimbursements will only increase in 2014. Healthcare providers will be especially concerned with curbing hospital-acquired conditions.

With three healthcare reform law financial penalties impacting quality of care starting or increasing this year, and numerous proposals and rules to add more components to each one, hospital and physician leaders may be forgiven if they're just a bit nervous about how 2014 will affect their operations.

There is no crystal ball. But these healthcare quality issues are certain to influence how hospitals and physicians deliver care in 2014.


See Also: Top Healthcare Quality Issues for 2014, Part 2


1. Hospital-Acquired Acute Kidney Injury
While HA-AKI is not yet part of any federal payment or penalty program, it is being increasingly recognized as a common type of patient harm that is, at least in many cases, preventable through better management and diligence.

Kidney injury affects between 7% and 18% of all hospital inpatients, and when hospital-acquired, is often the result of contrast agents used in cardiovascular procedures, or as a complication of nephrotoxic medications, according to a paper published last May in International Kidney, a journal of the by the International Society of Nephrology.

Such complications may be avoided, however, by using less contrast or less toxic medications, and being more aware of patients' renal health status before intervening with drugs or procedures.

The LEAPT (Leading Edge Advanced Practice Topics) program, part of Partnership for Patients, which is the Centers for Medicare & Medicaid Services' effort to push hospitals to reduce complications, has established "Hospital-Acquired Acute Renal Failure" as third on the list of avoidable harm initiatives, behind severe sepsis and prevention of Clostridium difficile infections.

"This has not yet been put forth as part of the inpatient hospital quality reporting program, so it would not be eligible for value-based performance payment at this point," says Richard Bankowitz MD, chief medical officer for the hospital quality improvement group and purchasing organization, Premier Inc. "However, the interest that CMS has expressed in this through the LEAPT program makes this a condition to watch."

CMS had proposed to add "contrast-induced acute kidney injury" to its list of hospital-acquired conditions for which the agency would not pay for additional required care, but has suspended that effort until implementation of ICD-10.

Look for HA-AKI to start getting reported in some format in coming years.

2. Readmission Penalty To Cut 3%
Adding to hospital concerns about loss of Medicare payments is the readmission penalty, which increases from up to 2% in the 2014 fiscal year, to as much as 3% of a hospital's Medicare DRG starting with discharges for the 2015 fiscal year.


See Also: Targeting All-Cause Readmissions an Ambitious Strategy


In addition to efforts directed at curtailing readmissions of patients initially treated for heart failure, pneumonia, and heart attack, CMS is adding hip and knee arthroplasty (THA and TKA) and chronic obstructive pulmonary disease (COPD) into the formula.

In its final rule, CMS officials pointed to two reasons for inclusion of hip and knee procedures. First, at least 1.4 million procedures were performed on Medicare beneficiaries per year, and because "combined, THA and TKA procedures account for the largest procedural cost in the Medicare budget."

And, the agency said, "Evidence also shows variation in readmissions of patients with THA/TKA procedures, supporting the finding that opportunities exist for improving care."

The agency added COPD to the algorithm because the median 30-day risk-standardized readmission rate for COPD in 2008 "was 22%, and ranged from 18.33% to 25.03% across 4,546 hospitals."

3. HAC Penalty To Cut 1%
The Patient Protection and Affordable Care Act called for a brand new penalty against hospitals whose rates of hospital-acquired conditions falls into the top quartile, starting Oct. 1, 2014, affecting up to 1% of a hospital's Medicare DRG payment. The equation consists of two parts. One is called patient safety indicator or PSI-90, an amalgamation of 11 indicators of harm including pressure ulcers, hip fractures, sepsis, and deep vein thrombosis.

The second category is a combination of the hospital's rates of central line-associated bloodstream infections (CLABSI) and its rates of catheter-associated urinary tract infections (CAUTI).

4. Videography in Surgical Skill Peer Review
Might surgeons soon be rated based on videos of their work?

A New England Journal of Medicine paper may have some surgeons and their medical executive committees trembling in fear or cracking open champagne. The study found that when surgeons watched procedure videos and rated their peers on skill and technique, their high or low ranking correlated well with the patient's actual outcomes and complications.

The surgeons were allowed to submit videos of what they considered their best work.

Not only did the reviewers find enormous variation on a 1 to 5 point scale, patients whose surgeons were ranked lower had twice the rate of death and other postoperative preventable events, such as readmissions and reoperations, as the surgeons who received the best scores.

Study author, John Birkmeyer, MD, director of the Michigan Surgical Collaborative for Outcomes Research and Evaluation, thinks the experiment, which was performed with experienced bariatric surgeons in Michigan, can be easily extrapolated to other surgeries and subspecialties.

The strategy, however, raises questions about what hospital leaders, in their role as physician employers or peer reviewers for staff privileges, should do with this information once they find a performer who doesn't measure up.

5. DSH Reductions
It remains unclear how soon and how fast, and which hospitals with large populations of low income, uninsured or underinsured patients, will lose their federal Medicaid and Medicare disproportionate share funding. But under the Patient Protection and Affordable Care Act, there's a presumption that more patients will be covered. Therefore the need for DSH to help hospitals cover their costs of uncompensated care would drastically drop.

In a letter last month to key Congressional leaders, leaders of nearly 100 hospitals and health systems protested said:

"Cuts to Medicaid DSH have recently taken effect, reducing federal support for our hospitals by $500 million this year. These cuts will get much larger in the coming years if you do not act now. If these crippling cuts are not stopped, our hospitals will be forced to curtail essential services, ultimately limiting access to care and cutting jobs. There is no connection between the cuts and the number of uninsured or amount of uncompensated care across the country. The level of Medicaid DSH cuts simply cannot be justified."

Other issues with respect to DSH funds have to do with approved delays in federal requirements under the law, which may result in more people than anticipated remaining underinsured in 2014.

6. Emergency Department Wait Times
With more patients having coverage through the health insurance exchanges and Medicaid, emergency room physicians are anticipating more crowding in hospital emergency departments. A recent New York Times article seems to provide evidence for that based on what has been observed in Oregon.

That's why emergency department wait time measures will become an increasingly transparent, publicized, and important way political leaders, consumers, employers and patients will compare quality of hospital care.

Now posted on Hospital Compare, these measures vary widely within communities and across the country. For example, at Kings County Hospital in Brooklyn, NY, patients needing inpatient admission waited on average 1,031 minutes, or more than 17 hours. But at St. Luke Hospital & Living Center in Marion, KS, patients waited only 63 minutes for admission.

7. Permanent SGR Repeal
Though Congress approved a three-month patch or bridge compromise, allowing a .5% physician pay upgrade instead of a 23.7% cut as required by the statutory formula of the sustainable growth rate formula, what quid pro quo will eventually be required will be the subject of much debate in March.

Bills that would permanently repeal the SGR set deadlines for EHR interoperability and make quality data required under an enhanced value-based purchasing program for physicians available to the public.

It would also bring a new level of transparency that quantifies physician payments and procedures.


See Also: Top 14 Healthcare Quality Issues for 2014, Part 2


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