Results of a "trifecta" of databases on provider quality and cost that will be released in 2015 are among the leading quality issues for the year.
Yesterday's list discussed misdiagnoses, star ratings, socioeconomic adjustment for readmissions, the end of Partnership for Patients programs, Medicaid parity expiration, and Disproportionate Share Hospital cuts. Today, seven more pressuring healthcare quality issues for 2015.
7. Antimicrobial stewardship as a Medicare condition of participation
By order of President Obama, healthcare settings of all types can and should do more to stem antibiotic resistant bacteria, which kills 23,000 Americans and sickens another 2 million annually.
This means imposing, by 2015 or at the latest, 2016, a requirement that hospitals and other inpatient facilities each have "robust antibiotic stewardship program" as a condition of participation in the Medicare program. The Department of Defense, the Veterans Administration system, and many other sites such as ambulatory surgical settings and outpatient clinics, must have in place such programs as well.
Top Healthcare Quality Issues for 2015, Part 1
APIC, the Association of Professionals in Infection Control and Epidemiology, applauds this move as one that will raise the importance of appropriate prescribing practices in preventing antibiotic resistant strains of bacteria.
8. Electronic quality measure reporting babble
The American Hospital Association points fingers of blame at the Centers for Medicare & Medicaid Services and the Office of the National Coordinator for Health Information Technology for failing to "enable electronic health records to generate feasible, reliable, and valid quality data for reporting purposes."
EHRs haven't undergone sufficient testing of measure specifications and data abstraction, AHA charges, and therefore the electronic clinical quality measure reporting they generate "do not provide accurate representation of hospital performance."
CMS should ensure that they do. And ONC, which manages certification of electronic health record systems, "should ensure that the certification requirements are specific enough to limit multiple interpretations by vendors."
AHA insists that certification should also include testing to assure that EHRs can report accurate clinical quality data.
9. Mining physician quality for contracts
Healthcare analytics companies are poised to mine three enormous data dumps on provider quality and cost, now in the public domain, to help health plans, employers, and even hospitals understand which providers to include in networks—and which to avoid.
Data from the Physician Payments Sunshine Act, the Medicare Provider Utilization and Payment database, and soon, quality data from the Physician Quality Reporting System make up "a trifecta" that such companies can use in an "infomediation" strategy for purchasers, says Paul Keckley, managing director for Navigant.
These analytics companies are "are going to employers, saying 'we can give you insight into which narrow network to contract with.' They're going to hospitals, saying, 'we'll show you which of your doctors is going to expose you to more risk for unnecessary care.' And they're going to the health plans, saying 'here's how to construct your networks, and by the way you probably want to think about bundled payments with this group of very efficient doctors.' "
10. PCORI research to vet which pricey drugs are better
With pharmaceutical companies rolling out price tags on hepatitis C drugs as costly as a high-end car (a 12-week course of the drug Sovaldi costs $84,000 and for Harvoni, $94,500), a $50 million project authorized in December by the Patient-Centered Outcomes Research Institute hopes to say whether they're worth it, and which is best.
The project will draw from electronic health records and other sources to find "real world evidence of their long-term effectiveness" and comparative effectiveness that's now lacking, says PCORI executive director Joe Selby, MD.
With information about comparative quality, health plans may have the basis to limit their formularies, or at best, "decide why one drug ends up at a level 3 copay, and another a level 2," Keckley says.
11. Cuts, cuts, and more cuts to doc pay for care to the poor
Numerous threats to federal support for Medicaid and Medicare continue. They include the unknowns subsequent to the March 31, 2015, expiration of the sustainable growth rate (SGR) fix, the "primary care cliff" taking effect in October affecting $3.6 billion in money for community health centers, and other proposals to set an annual cap on physicians' Medicaid pay.
Still in discussion are efforts to reduce the deficit by curtailing how much money Congress allows for state Medicaid subsidies, which typically average about 50% of Medicaid physician pay.
12. Gaggle of quality reporting
The Hospital Compare website now includes data for 100 quality measures, along with volume statistics for 35 medical conditions and surgical procedures for each hospital. Meanwhile, numerous organizations list their top 100 hospitals in such a way that virtually every hospital in the nation can claim it's the best, at least in something.
The multitude of reports makes it difficult for providers to understand their own vulnerabilities. The AHA lists this issue as its top quality issue for 2015. "The tremendous volume of quality measures among Medicare, Medicaid, and private payers has become overwhelming," says Jennifer Schleman, AHA spokeswoman.
It's tough to figure out how to report these measures, for different payers require different definitions. The list of measures "should be minimized and prioritized to those that are the most important to ensure patient safety, good outcomes, and improvements in care. They also must be coordinated and synchronized across various payers, payment systems, and settings of care to reduce the reporting burden on hospitals and health systems," Schleman says.
13. Healthcare fraud
The case of Detroit oncologist Farid Fata, MD, charged with operating a $35 million Medicare fraud scheme that involved diagnosing and treating patients for cancers they didn't really have or need, illustrates that healthcare fraud is not going away, and still goes on in the open.
Fata, described by the Detroit Free Press as being a "onetime prominent cancer doctor," administered potentially harmful chemotherapy to countless numbers of his 1,200 patients and pled guilty to 16 counts.
What is equally horrifying is that a chemotherapy nurse who witnessed him engaging in improper procedures tried to blow the whistle on him by asking the state to investigate in 2010. But according to her, the state found no wrongdoing.
Cancer care is increasingly coming under scrutiny not just for the cost of its care, but also for more appropriate, less harmful treatments. Numerous quality measures are in the works for breast, colon, and prostate cancer that will help providers and consumers understand what's right and what is wrong.
In an April 2012 study, former CMS administrator Donald M. Berwick, MD, and RAND Corporation analyst Andrew D. Hackbarth estimated that fraud and abuse "represented between $82 billion and $272 billion in wasteful spending in 2011," and as much as $98 billion in waste to the Medicare and Medicaid programs, in 2011 alone.
Just think of what the U.S. healthcare system could do with $98 billion.