Pros and Cons of The Quality Initiative R H Haralson III, MD, MBA [email protected]

Pros and Cons of The Quality

InitiativeR H Haralson III, MD, MBA

[email protected]

North Carolina Medical Society 2008

Problem 1QUALITY

• The quality of medical care– IOM study – “To Err is Human”– 50% of treatment we render is inappropriate

• (Elizabeth McGlynn)

– The older the physician the worse it is– Cost and quality have an inverse relationship


Orthopaedics• Fractured hips (9 parameters)

– Prophylactic antibiotics

– Prophylactic thromboembolism medications

– Proper lab work• Coagulation profile


OrthopaedicsReceived appropriate regimen

22%


Problem 2COST

The cost of medical care– To build a car, it costs more for medical

insurance than metal– The cost of medical insurance is more than a

minimum wage earner’s annual salary

– 16% of the GNP

– It is un-stainable




Alphabet Soup of the Quality Initiative

• PCPI – AMA Physician's Consortium for Performance Improvement

• NCQA – National Committee for Quality Assurance (HEDIS and Managed Care)

• NQF – National Quality Forum• AQA – Ambulatory Quality Alliance (AHRQ)

• HQA – Hospital Quality Alliance

• SQA – Surgical Quality Alliance


Pros• Theoretical

– Increase Quality (Safe, Timely, Efficient, Effective, Equal, Patient Centered)

– Decrease costs• Quality is cheaper

• Practical– If we don’t do it, it will be done for (to) us


Pros• Reduced practice variations• Catalyzes investment in HIT• Incentives for preventative care• Incentives for health plan

competition


ConsProcess vs. Outcomes–We want outcomes

–Process can be a surrogate for outcomes (audit)

–Outcomes point out a problem but does not identify the source


ConsNo good way to risk adjust–Especially in surgery

–Co-morbidities

–Patient non-compliance

–Cultural and religious differences

–Statins example


ConsAttribution–Care provided by multiple providers

• Fractured hip with cardiovascular disease

• Fractured hip with osteoporosis

• Assigning measures to a specialty


Rebuttal

With large population studies, risk adjustment and

attribution are not necessary


Cons• No good surgical measures

• Need to be under the control of the surgeon

–Infection rate

• Better for chronic conditions (Diabetes, Heart Disease and Asthma)


ConsIncrease efficiency and conservatism results in decreased revenue– Payment system must be revised

• (Part A and Part B)

– Need to pay more for conservative treatments

– The fact that P4P programs are added on top of existing fee for service programs leads to conflicting incentives


Cons• Unintended consequences

–Measuring Hgb A1c in diabetics• Did the doc do anything about it

–Examination of the retina• Control of hypertension is much more

important


Cons• Incentives

– 1% - 2% too low

– 10% about right but that may lead to increased costs

– The incentive must be greater than the incentive to produce

• Where does the money come from


Cons• Do you reward improvement or

maintenance – The terrible get better (tier 4 to tier 3)– The best cannot get better– Some think recognition is enough

• What about punishment of those that do not meet the benchmarks (Tournament approach vs. rewarding anybody)


ConsEffeciency measures

Cost / quality = Efficiency

Cost = episodes of care (groupers)

Cost (bad number) / Quality (bad number) =

Nirvana (efficiency)


Cons• Errors in reporting

–Wash. U. experience

–Black boxes

–Transparency

–Lack of appeal mechanism


Cons• Burden of collecting data

– Databases are wonderful but somebody has to enter the data

– Payers want available data

– Chart abstraction

– EMR will eventually be necessary• Voice recognition• Point and click (Structured Data)


Cons• So far the data demonstrating success of

P4P is sparse.– Some success but moderate– Problems with low financial incentives– P 4 Performance vs. P 4 Reporting– Low hanging fruit




Theoretical Con• Med Students and interns are taught to

think sequentially or longitudinally

• Emergencies require thinking and acting at the same time

• Physicians need both

• EBM leans toward sequential thinking

• Read “Blink” and “How Doctors Think”


Theoretical Con

• “Rare things don’t happen very often, but they do occur”– Harold Boyd, MD

• You must not forget to look for Zebras


PQRI, 2008• Voluntary

• All of 2008

• Incentives are the same (1 ½%) (sort of)


PQRI, 2008• Must report 3 measures on 80% of your

eligible patients for the full year• 1 ½% bonus (Calculated on all your

Medicare billings)• Tracked by Unique Identifier (NPI)

– https://nppes.cms.hhs.gov/NPPES/

• Paid by pay number

https://nppes.cms.hhs.gov/NPPES/


Surgical Measures• Prophylactic antibiotics within 1 hour

of surgery

• Use of a first or second generation cephaolsporin

• Discontinue antibiotics within 24 hours

• Thromboembolic prophylaxis


10 Orthopaedic Measures• Communication with PCP

• Screening for future Fall Risk

• Screening for Osteoporosis

• Management following fracture (DEXA)

• Pharmacological Therapy

• Counseling on use of vitamin D and Counseling on use of vitamin D and exerciseexercise


4 New Measures• Adoption of Health IT

• Adoption of E-prescribing

• Diabetic vascular exam

• Diabetic foot ulcer exam


Other Possibilities

• Medication reconciliation

• Disease modifying anti-rheumatic drug therapy in rheumatoid arthritis

• Inquiry regarding tobacco use

• Advising smokers to quit.


How Do I Report?

• CPT Level II code on the CMS 1500 form along with your procedure/management code (4047F)

• Modifier– 1P I did not do it for a reason

– 8P I did not do it for no reason


• AAOS PQRI WORKSHEET

• Measure #20: Perioperative Care: Timing of Antibiotic • Prophylaxis–Ordering Physician CPT II 4047F, 4048F, • Modifier 1P:

• SURGICAL PROCEDURECPT CODE• Spine 22325, 22612, 22630, 22800, 22802, 22804, 63030,

63042• Hip Reconstruction 27125, 27130, 27132, 27134, 27137, 27138• Trauma (Fractures)27235, 27236, 27244, 27245, 27758,

27759, 27766, 27792, 27814• Knee Reconstruction 27440-27443, 27445-27447• Neurological Surgery 22524, 22554, 22558, 22600, 22612,

22630, 35301, 63015, 63020, 63030, 63042, 63045, 63047, 63056, 63075, 63081, 63267, 63276


Resources

www.cms.hhs.gov/pqri

www.aaos.org/pqriArticlesWebinarWorksheetsStep by step instructions

http://www.aaos.org/pqri


Latest ConceptsCare Coordination

Communication among all care givers, caring for a patient, in an effort to fully inform all caregivers of the necessary

medical information to achieve continuous, safe, timely, effective,

efficient, equitable and patient centered medial care.


Care CoordinationMedical Home

Does not have to be a PC


Latest Concepts

Composite Measures

Combination of several measures like McGlynn


Summary

• Pros - short list (quality and cost)–Rewards are possibly great

–Consequences of not doing it are disastrous


Summary

• Cons - Long list with lots of problems– All are remedial

• Eventually it will look different

• We will always have to prove quality

• What will really help is when we measure the insurance companies


Prediction1. Quality reporting is here to

stay2. Eventually it will not be

“P4P”, it will be

“Report to Survive”


Admonishment

“If we do not make this quality movement work, it will all be on cost.”

Susan Nedza, MD

Chief Medical Office , CMS, Now VP AMA


Thank YouThank You

Documents

Pros and Cons of The Quality Initiative R H Haralson III, MD, MBA [email protected]