For the dozen years that the National Committee for Quality Assurance (NCQA) has been compiling its annual State of Health Care Quality report, "there's never been a more opportune time" to present this report, said NCQA President Margaret E. O'Kane Thursday at a news conference in Washington. "As we speak, decisions about our healthcare system are being made on Capitol Hill that will affect our country's future. We can't afford to get this wrong: The money and the human costs are too high."
The problem this year, though, is that for the most part, "the quality results are not at the same level of improvement that we've seen in the past," she said. In other words, they have been flat, stagnant—or just plain stuck in neutral compared with previous years.
The trend was seen in care provided to people with private insurance coverage, as well as Medicare and Medicaid coverage. For commercial plans, 57% of measures showed no statistically significant improvement; for Medicaid Plans, 64% of measures showed no statistically significant improvement; and for Medicare Plans, 86% of measures showed no statistically significant improvement.
"There are some bright spots, but overall, we feel frustrated that we don't seem to put our power behind what we really want. So if we really want quality, we need to send a signal to all phases of the healthcare system that we're really serious . . . that we have to be very clear about what we want and then put our money where our mouth is."
To turn this trend around, lawmakers on Capitol Hill should consider several areas of reform, O'Kane suggested:
Create insurance exchanges and require participating plans to maintain accreditation that assesses clinical quality and patient experience.
Reform payment and delivery systems to reward quality performance and spur care coordination.
Focus on quality improvement in Medicare and Medicaid.
"Everybody in American deserves to have the best healthcare," she said. Improving healthcare quality can have significant benefits beyond the healthcare system itself. NCQA estimates that were all health plans able to perform at the level of the top 10% of plans, the U.S. would avoid between 49,400 and 115,300 deaths annually and save at least $12 billion in medical costs and lost productivity every year.
This year, NCQA's State of Health Care Quality Report examined quality data submitted by an all time high 979 health plans across the country that collectively cover 116 million Americans—a 9% increase over 2008. Plans submit data using NCQA’s Healthcare Effectiveness Data and Information Set (HEDIS), a set of measures that assess how often patients receive care that conforms to evidence based guidelines.
And while the data show that the system has hit a "performance plateau," some bright spots did emerge, such as a 12% jump in the provision of beta blocker drugs to Medicare patients who had a heart attack within the previous six months, and substantial gains in helping Medicaid beneficiaries stop smoking.
Quality of care, though, tended to vary sharply depending on where people live. NCQA’s analysis of care for several chronic illnesses found that people in some parts of the U.S. were far less likely to receive appropriate care than were people in other parts of the country.
Health plans in the New England region continued to outpace all others and the quality of care in the South Central region tended to lag the most. Among the findings:
Health plans in New England were 16.3% more likely to treat diabetic patients according to accepted guidelines compared with health plans in South Central states;
Health plans in Mid Atlantic states were 14.1% more likely to adhere to guidelines for treating patients with cardiovascular disease compared with plans in South Central states.
New England health plans were 19.2% more likely to ensure that all patients received all appropriate cancer screenings compared with health plans in South Central states.
Health plans in Pacific states were 20.8% more likely to appropriately treat and follow up with patients with mental health and substance abuse issues compared with health plans in West North Central states.
Also for the third year, NCQA measured the value of health plans by combining quality measures with assessments of how many resources were used to achieve those results. Data were collected in four key chronic disease areas: diabetes, cardiovascular disease, asthma, and chronic obstructive pulmonary disease. Wide variations were reported in both spending and quality—with essentially no relationship between cost and quality.
With all these statistics, though, O’Kane suggests that one point needs to be kept in mind: "Quality needs to be the foundation of health reform."
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The American Medical Association today launched a new Web-based program to improve patients' and physicians' communication and coordination of care for seasonal flu and the H1N1 virus. AMA is touting the Web site, AMAfluhelp.org, as the nation's first comprehensive Web-based patient flu health-assessment program.
"This resource allows patients to assess their symptoms and determine when to seek care for themselves or their loved ones," said Mary Anne McCaffree, MD, an AMA board member. "To prevent the spread of influenza, this site also helps determine when it is safe for those who have been sick to return to work or school."
The Web site asks patients questions to determine the severity of their flu symptoms based upon the latest CDC guidelines. Patients can share their information with their physician, as well as family members and loved ones. AMAfluhelp.org also provides a set of online tools to help physicians monitor their patients' symptoms, facilitate care and treatment decisions, and efficiently manage their practices' patient flow.
AMAfluhelp.org can help patients assess their own flu symptoms, or those of a child or loved one, and offer guidance on whether they should seek care. There is also a choice for pregnant women to evaluate their need for a flu vaccination and for all patients to monitor any post-vaccine related symptoms. AMAfluhelp.org can also generate a doctor's note when it is safe to return to work or school.
The Web site is in collaboration with the Flu Information & Care System, which includes: AllOne Health, BlueCross NEPA, CVS Caremark, EMSC, HealthyCircles, HERAE, Merck, MedImpact, Microsoft, Minute Clinic, Schumacher Group, Staywell/Krames, Team Health, and WorldDoc.
There's no question that audit activity is escalating and the healthcare provider community needs to find a way to deal with the higher volume of audits and increasing number of auditors conducting them.
It's no longer just RAC, MAC, CERT, and ZPIC audits looking to ensure the accuracy of Medicare payments. Providers are also subject to increased scrutiny on the Medicaid side, as states are working with the federal government to help reduce payment error rates and recoup overpayments.
Providers in some states may be ill prepared for the increase in audit activity. "Some states have been more aggressive recently and some states have not had the resources to do it. But I think it is going to be a wakeup call in those states where enforcement has not taken place to receive and respond to the audits," says James G. Sheehan, the Medicaid inspector general for New York.
"It is very challenging. The audits are stacking up," according Sarah Kay Wheeler, partner at King & Spaulding LLP in Atlanta. "And add to the list is the Medicare Advantage plans contracting with different groups to conduct independent audits for Medicare Advantage purposes."
Sheehan agrees that Medicare Advantage auditing is probably on the horizon, and believes providers may also need to watch out for Medicare Prescription Drug Benefit program audits. "I think it is reasonable to expect that the lessons that CMS learns in calculating estimates of improper payments and in auditing will be extended to the Medicare Prescription Drug Program and the Medicare Advantage Program going forward."
For now, providers should definitely spend time preparing for Medicaid Integrity Contractor audits, as these should begin in all states by the end of 2009.
What will MICs be auditing? It will vary from state to state, of course. But Sheehan believes some of the following may be issues on which MICs will focus, at least at first:
Dead or alive. In other words, was the patient alive at the time that the treatment was allegedly rendered to him or her? "This may seem obvious, but in a number of states their system controls process usually takes three to four months to identify a patient as deceased," says Sheehan. "That's a pretty straightforward issue for the MIC to focus on." In addition, MICs may look at whether a physician was deceased at the time he or she allegedly wrote an order, he says.
Inpatient at time of ambulatory service. MICs will look for patients who were inpatients at the hospital at the time they were given home healthcare or ambulance trips.
Hysterectomy on males. This is just one example of inconsistent coding, Sheehan says. "There are computerized techniques for identifying things that are impossible or highly unlikely. Hysterectomy on a male is one of them."
Debridement requiring actual cutting. MICs will look at regulations and statutes and coding guidance, such as Coding Clinics.
Heart failure and shock. For this issue, MICs will look for failure to meet InterQual criteria for inpatient care.
Ambulatory surgery with no complications to justify inpatient stay. "Commonwealth Fund just came out with a ranking of the states on this issue, and some states are better than others. It may not be a bad idea to find out where your state stands and whether this will be an issue," Sheehan says.
DRG assignment. Take a code pair with pretty clear criteria (e.g., temporary paralysis vs. more permanent paralysis) and examine which code pair you report more often. If you are heavily weighted toward the more expensive and many other hospitals are weighted the opposite way, you might want to take a good hard look, says Sheehan.
Observation beds. This is always a popular issue because Medicaid rules differ by state and also differ from Medicare in most states, explains Sheehan.
Exclusion. "This is my personal prediction … Over the last three years, the OIG has issued guidance on exclusion that says you can't even have a janitor who is an excluded person working for your organization if you're getting paid Medicare or Medicaid money that finds its way in whole or in part into his salary," says Sheehan, who is finding that many providers don't have the necessary screening in place to prevent employment of persons excluded under state or federal law. "You may want to take a look before the auditors come in at 42 CFR 402.209, which talks about the scope and effect of exclusions. Because I find in my own work there's not as much awareness of these issues as there should be. And it's an easy data run to do if you are a MIC."
Feeling overwhelmed? When it comes to MIC audits, you may have an ally. In New York, for example, a topic on the table is minimizing the burden on hospitals and other providers. So Sheehan suggests that if you're overwhelmed and your MIC isn't responsive, it might be wise to go to the program integrity head in your state.
"If you don't get a positive response from your MIC when you say, 'Hey, we've got 20 audits stacked up here. Can you please take your place in the queue?' then go back to the state and tell them you need some relief in the short term."
I spoke recently with John Bardis, CEO of MedAssets, a healthcare supply chain and revenue cycle management company, about his crusade against the lack of transparency in durable medical devices, contracts for which preclude hospitals from disclosing how much they pay for such devices. Bardis thinks this lack of transparency is the top financial challenge facing hospitals, and there?s precious little in healthcare reform legislation that will shine a light on the murky way device companies keep prices artificially high.
Enrollment in both new and existing U.S. medical schools continues to expand to meet the nation's need for more doctors, according to data released by the Association of American Medical Colleges. First-year enrollment in the nation's medical schools rose this year by 2% over 2008 to nearly 18,400 students.
Larry Garber, MD, medical director of informatics at Fallon Clinic in Worcester, MA, talks about his experiences implementing a personal health record system and how it has affected physician-patient relationships. [Sponsored by Emdeon]
Although the CME standards the ACCME put in place in 2006 (facilities have until 2012 to fully comply) aren’t asking CME providers to track exactly what physicians learn, they require CME to be:
Focused on practice-based learning
Derived from the physicians’ professional practice gaps
Designed to change physician strategies, performance, or patient outcomes
Evaluated for its effectiveness in changing strategies, performance, or patient outcomes
"CME is becoming more aligned with performance improvement. Basically, what the ACCME is saying is that CME doesn’t make sense unless it addresses a bona fide need and leads to some real change," says Charles Huntington, PA, MPH, associate dean of continuing and community education at the University of Connecticut School of Medicine in Farmington.
Although meeting these requirements sounds daunting, small changes can make a big difference. For example, the University of Connecticut School of Medicine is pushing its various departments to revise their educational interventions to solicit audience participation. "Although there may be a component that is didactic, they really need to allow time for audience discussion," says Huntington.
One department is doing a particularly good job of engaging participants, he says. Each CME topic is covered during the course of two or three sessions, and at the end of the first session, the presenters ask the audience members what they want to learn more about. Presenters then use this information to develop the next two sessions.
The university is also focusing on CME that engages physicians in performance improvement projects within their areas of practice. Practitioners who engage in this type of CME must define an area they want to improve, measure their current performance, plan and implement a process change, and measure the effectiveness of the change.
"This is a real culture change. We are asking our providers to think about CME in a very different way," Huntington says.
This article was adapted from one that originally appeared in the October 2009 issue of The Doctor’s Office, a HealthLeaders Media publication.
The future of physician reimbursement is now officially tied to the outcome of healthcare reform efforts. Yesterday, the Senate failed to garner enough votes to overcome the filibuster of S.1776, known as the Medicare Physician Fairness Act, which would have eliminated the 21% Medicare physician reimbursement cut set to take effect in 2010.
Unless additional legislation is introduced, the only remaining hope for eliminating the cuts mandated by the Sustainable Growth Rate formula is in HR 3200, the House healthcare reform bill.
We've been through this song and dance routine many times before, and for several years Congress has intervened at the last minute to prevent Medicare cuts that would have slashed physician pay and led many providers to stop accepting Medicare patients. Only this time the cut is much larger and the Congressional intervention is happening in the middle of a heated ideological debate about broader healthcare reform.
Which is probably why Senator Bob Corker (R-TN) called the legislation "a ponzi scheme" and asked his Senate colleagues to revolt "against this most sinister act."
Corker and other Republicans argue that Democrats are trying to handle the physician payment fix separate from healthcare reform legislation in order to deceptively keep reform budget-neutral. There's a point to that. Eliminating doctor pay cuts adds nearly $247 billion to the deficit over 10 years, and Democrats don't want that to count against them.
But in many ways it is a separate issue. Even if Congress wasn't debating reform, even if the current reform bills were withdrawn from consideration tomorrow, physicians would still be facing a 21% reimbursement cut and Congress would still be forced to debate the consequences of letting the cut take effect.
The physician fee schedule is like that frequent flyer patient that keeps showing up on the operating table; let's call him Steve. Steve smokes. He's obese. He doesn't exercise or utilize preventive care, and each year the poor health catches up with him when he's rushed to the hospital after a heart attack for a major, life-saving intervention.
Thanks to last-minute action, Steve hasn't died yet, but he hasn't gotten noticeably healthier, either. Each year he's back again, only a little worse for wear. Those Medicare cuts are growing exponentially—last year's would have been 10.6%, and the ones before that were only single digits. By 2016, they're scheduled to add up to 40%.
The Medicare Physician Fairness Act would have gone much further than previous efforts. Instead of a one-time intervention—a Band-Aid, as it has often been called—it would have essentially reset the payment updates at zero and repealed the SGR formula altogether. The AMA, AARP, and other groups understandably campaigned intensely to make this happen.
In our analogy, this bill would have given Steve a coronary stent, blood pressure medication, and set up an appointment with a primary care doctor to ensure that he doesn't end up in the emergency room for a long while.
But S. 1776 didn't offer a replacement for the SGR methodology, so it would have prevented annual emergencies but stopped short of a sustainable fix. In Steve's case, any treatment is limited in its effectiveness if he continues his current lifestyle. If he doesn't lose weight and stop smoking, he's not getting at the underlying drivers of his health problems.
Similarly, S.1776 was good as far as interventions go, but Congress is still missing the underlying "poor health" of the current physician reimbursement system. It's the fee-for-service payment model, which rewards quantity over quality, that is driving a good chunk of healthcare costs, and that system remains intact.
To their credit, reform advocates in Washington have talked about the importance of changing the fundamentals of physician reimbursement to better reward quality. They've also talked about the importance of rewarding patient behavior changes to get at core health problems like obesity. But they haven't included major solutions to either in the bills.
Reform legislation in the House can still prevent the 21% cut and kill the SGR formula for good, but it also stops short of offering a compelling replacement.
"We'll take this up again when we finish healthcare, and we'll have a multiple-year fix for this," Senate Majority Leader Harry Reid (D-NV) said yesterday after S. 1776 failed. "Right now, we'll only have a one-year fix."
Meanwhile, Steve is lying on the operating table, waiting for January 1.
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The California Nurses Association announced this week a potential one-day strike on October 30 because of hospitals' lack of protection against the swine flu for its members. The strike would involve more than 16,000 registered nurses at more than 30 hospitals, targeting the San Francisco-based Catholic West hospitals in California and Nevada.
Nurses have been trying to resolve contract issues with the hospital system regarding pay, healthcare benefits, and adopting state guidelines for responding to H1N1 flu. Earlier this year, the Division of Occupational Safety and Health published the state guidelines that the nurses wish the hospital system would adopt. Specifically, they want N95 protective masks distributed to nurses and isolating infected patients.
Also, in the negotiations, is putting a stop to "floating," which is when nurses are assigned to areas outside of their expertise. This could mean asking a labor and delivery nurse to cover the emergency room.
Concern for the nurses' own safety from H1N1 flu has risen since the death of one of its members this past summer. The nurse died of a severe respiratory infection, pneumonia, and H1N1. The nurses hope to establish safety procedures around the U.S. with the contract negotiations.
Hospitals that could potentially be affected by the strike include California Hospital Medical Center, St. Vincent Medical Center, Glendale Memorial Hospital and Health Center, St. Mary Medical Center in Long Beach, Community Hospital of San Bernardino, and St. Bernardine Medical Center in San Bernardino. Nurses are also planning to picket two Catholic Healthcare West hospitals in Nevada.
Five healthcare officials from varying parts of healthcare said a new global payment system would reward physicians for quality and care coordination, reduce over-utilization, and would pay for results rather than services.
Speaking at the Center for Connected Health's sixth annual symposium Wednesday, Tom Lee, MD, network president at Partners HealthCare, said the health system should focus on improving value rather than bending the cost curve. Lee said one misconception is that global payments will result in cheaper per member per month payment. Instead, global payments provide better quality, he said.
"[A global payment structure] is not going to solve the cost challenges we have," said Lee, who is a physician. "I think the future is groups thinking about value in a disciplined way."
Robert Mechanic, senior fellow and director of Brandeis University's Health Industry Forum, said global payments are an opportunity to shift to a system that rewards higher-value activities and enables providers to use technology like online consultations and home monitoring.
One example of a move to global payments is Massachusetts. A state coalition of healthcare stakeholders recently recommended that the state move from a fee-for-service structure to global payments.
Glen Shor, the assistant secretary for healthcare policy in Massachusetts who worked on the payment reform effort, said state leaders still need to work out details in the plan, such as whether Massachusetts will create an oversight entity to help steer payment changes and make sure there are no legal or antitrust barriers in place that would impede the payment reform.
Massachusetts will also have to help providers move to global payments by educating them about contracting and care coordination practices, he said.
Mechanic said the Massachusetts payment change sets a definite timeframe in which providers can transition to global payments. But it also allows for flexibility to allow providers to remain in the fee-for-service structure if they prefer.
"We need to have an approach that is flexible," said Mechanic, adding that a new payment structure should also reward physicians who make the switch to global payments.
Another example of global payments is Blue Cross Blue Shield of Massachusetts, which offers providers an Alternative Quality Contract (AQC). BCBS of MA give providers who take part in AQC a baseline payment that is the same as the current fee-for-service contract as well as bonuses of up to 10% if the providers reach certain quality goals.
Andrew Dreyfus, executive vice president at BCBS of MA, said AQC is different from capitation, which is often criticized as a failed managed care relic of the 1990s, because AQC provides incentives and health status adjustments in the payments, which will sway doctors from declining care to high-cost patients. BCBS of MA will also share risk with physicians and hospitals through reinsurance and stop-loss insurance, he said.
"We have tried to build a global payment 2.0 if you will—a new system that works with physicians," said Dreyfus.
All of the health officials agreed that physicians must play a key part in payment reform. Lee said he hopes for a "co-evolution" in the way that providers and payers relate to one another, which will create a system will more efficient care.
His fears are that either payment reform is not well thought-out and causes a provider backlash or—even worse—there are no attempts made to move away from the fee-for-service system.
"If we're unable to do anything, then we'll have the same fragmented payment system, but increasingly inadequate," said Lee.
Miller said physicians have to be the ones pushing for payment reform. Having policymakers tell providers how to do things won't gain physician support, he said.
Lee said he was a capitation booster in the 1990s and learned from the experience that providers must understand risk—and the system can't merely put all the risk on providers.
In addition to educating physicians and getting buy-in, Miller said the healthcare system must educate patients in terms like the medical home and global payment. They may mistakenly think the terms mean nursing home and needing to get care in another country, he added.
Part of that education is telling people that global payments will not lead to "rationing," but are a way to incentivize doctors who keep patients out of the hospital, cut down hospital infections, and reduce costs, said Miller. He added that a new payment system must also involve patients by rewarding those who choose the highest quality providers.
