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Top Healthcare Quality Issues for 2015, Part 1

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   January 06, 2015

Six quality issues warrant the attention of healthcare leaders: misdiagnoses, star ratings, socioeconomic adjustment for readmissions, the end of Partnership for Patients programs, Medicaid parity expiration, and Disproportionate Share Hospital cuts.

Healthcare has experienced fascinating changes during the last few years, and 2015 will be no exception.

Major programs stemming from the Patient Protection and Affordable Care Act are well under way, dozens of new quality measures and data galore are flowing into the public domain, and quality of care remains in the spotlight for providers at all levels.

There are sure to be tweaks, especially where measures and performance commingle to affect payment. But here are six quality issues that warrant your attention in 2015.


>>>Slideshow: Top Healthcare Quality Issues for 2015

1. Measuring misdiagnosis

If physicians' diagnostic accuracy were like air travel, one in 20 planes would not land when or where it should, and one in 40 flights would put passengers at risk of significant harm, or even crash.

Those are estimations from an April 2014 report from Houston Veterans Affairs and Baylor College of Medicine researcher Hardeep Singh, MD, and colleagues who say that 12 million U.S. outpatient adults may be given incorrect or delayed diagnoses every year. Singh says reducing misdiagnosis must be a major quality focus for 2015 because providers and patients should not tolerate error rates this high.

Top Healthcare Quality Issues for 2015, Part 2

Singh's report in BMJ Quality & Safety estimated that 5.08% of outpatients receive an inaccurate diagnosis, and that half of those errors have the potential to cause severe patient harm, such as a missed opportunity to treat cancer at an earlier, easier stage. These misdiagnoses can result in avoidable or extended hospitalizations or even death.

Though misdiagnoses may be a patient safety issue on a par with medication errors or infections, providers don't measure or track them. It can be hard to assign blame: sometimes patients don't know or fail to reveal relevant details. But sometimes the fault is the provider's, for failing to take an adequate history or conduct a proper physical exam.

"Misdiagnosis is the next frontier in patient safety," says Rosemary Gibson, a senior advisor at the Hastings Center and author of numerous books on quality, such as The Treatment Trap and Wall of Silence. Poor residency training programs are also at fault, she says.

Momentum is building. In 2012, national patient safety leader Mark Graber, MD, and others launched The Society to Improve Diagnosis in Medicine, and in 2014, misdiagnosis got its own peer-reviewed journal, Diagnosis.

2. Hospitals to get star ratings

Some will get five stars, some four, some three. And some hospitals will be tagged by the Centers for Medicare & Medicaid Services with two or even one star, signifying organizations that could use some quality interventions.

The five-star rating system for hospitals was scheduled to go live on Hospital Compare in December, but the update is delayed until April 2015 for HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) and until sometime in 2016 for an all-hospital star rating, according to CMS spokesman Don McLeod.

In a summer blog post, CMS medical director Patrick Conway, MD, wrote that the star ratings are based "on established scientific standards of rigor and accuracy" and will be posted for many types of care "early in 2015."

Hospitals that don't get five stars may not see it quite the same way.

3. Readmissions socioeconomic adjustment

The American Hospital Association and America's Essential Hospitals provide solid backup for their claim that CMS's refusal to adjust readmission rates and other quality measures for hospitals with more low socioeconomic status is unfair and requires immediate remedy.

For starters, low SES patients have more difficulty filling necessary prescriptions and scheduling a physician's visit following hospital discharge—factors that aren't under the hospital's control—and hospitals shouldn't be penalized because of it.

Even a top official for the National Quality Forum, Helen R. Burstin, MD, now agrees, writing with two others in a recent JAMA Viewpoint that "this policy of not including risk adjustment, adopted by [CMS] and others, potentially results in unfair comparisons among clinicians, hospitals, and other healthcare organizations."

But CMS has refused to relent. In its Aug. 22 final Inpatient Prospective Payment rule, the agency said "we continue to believe that the same care protocols and processes that are successful in caring for non-low-SES patient populations may also be successful in caring for low-SES patient populations."

But CMS may soon be forced to give in. The NQF board in July voted to amend its policy against sociodemographic risk adjustment to allow a "robust trial period" to see if a new algorithm is warranted. But rather than adopt an adjustment factor for all quality measures, the NQF may go for a "nuanced approach" in which some measures will be designated appropriate for an SES adjustment, and some won't.

Additionally, two Congressional bills, S. 2501 and H.R. 4188, would require CMS to include an adjustment factor in its readmission algorithm

"We can't continue to ignore the influence of sociodemographic factors on the measures we use for quality improvement [because] abundant research shows that poverty, lack of family support, language barriers, and other sociodemographic challenges make a difference in health care outcomes" says Bruce Siegel, MD, president and CEO of America's Essential Hospitals.

His members, primarily safety net hospitals, "face disproportionate penalties in these programs," whose penalties create a "vicious circle that actually threatens quality by reducing scarce resources at these hospitals," he said in an e-mail response.

4. Demise of the Partnership for Patients

The Obama administration has proudly credited Partnership for Patients programs such as the 26 Hospital Engagement Networks and the Community-Based Care Transitions Program, enabled by $800 million in federal funds since 2011, for improving hospital care.

But funding for the HEN programs ran out Dec. 31, 2014, and the CBCT money ends in 2015, leaving hospitals clueless about what worked and what didn't.

Many healthcare leaders will watch closely to see if those programs instilled permanent cultural changes to maintain the improvements, or whether the reductions in adverse events are the result of more careful clinical documentation.

5. Medicaid parity expiration hurts doctor supply

Expansion of Medicaid in all states was one goal of PPACA, which allows financial enticements to enlist more primary care physicians to accept Medicaid patients, hopefully speeding access to care.

To accomplish that, Congress set aside $12 billion to subsidize Medicaid payments for primary care providers and pediatricians up to Medicare levels for two years. A December Urban Institute study estimated that the "fee bump" increased Medicaid payments by 73% on average.
The bump came just in time too, because 7.5 million Medicaid enrollees have been added in 27 states and the District of Columbia since the third quarter of 2013, the report says.

But that subsidy expired Dec. 31, 2014, plummeting Medicaid payment rates back to their former state-set levels. And while 15 states will continue the fee increase with state funds, 24 won't and the rest remain undecided. It's important to note that 71.3% of the nation's 68 million Medicaid enrollees reside in those 24 states that won't continue the increase, including the biggest: California, New York, New Jersey, Florida, and Pennsylvania.

And while it's unclear whether the parity bump was in place long enough to sign up more physicians for the Medicaid program, its loss—at a time when Medicaid patient rolls keep growing—may provoke many doctors to drop out of the Medicaid program for good, or at the least limit the time they spend with their patients, which is certain to affect quality of care.

For Reid Blackwelder, MD, past president of the American Academy of Family Physicians, loss of Medicare would threaten not just the willingness of physicians to accept Medicaid patients, but also physician morale and willingness to accept those patients.

6. Disproportionate Share Hospital cuts remain unfair

America's Essential Hospitals and other organizations continue to argue that an important element of the PPACA, a gradual reduction in subsidies for hospitals with disproportionate shares of uninsured and underinsured patients, is based on an assumption no longer true.

The idea was that the subsidies should taper off because more states would expand eligibility criteria so more Medicaid patients could receive health benefits. But the U.S. Supreme Court's 2012 decision made states' Medicaid expansion voluntary, and only half of the states have expanded their criteria to date.

"Given this outcome, scheduled DSH cuts that reduce federal support by about 50% by 2019 can no longer be justified," says an Essential Hospitals statement.

Tomorrow: Part 2 of the list of top healthcare quality issues for 2015.

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