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Pros and Cons of The Quality Initiative R H Haralson III, MD, MBA

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Presentation on theme: "Pros and Cons of The Quality Initiative R H Haralson III, MD, MBA"— Presentation transcript:

1 Pros and Cons of The Quality Initiative R H Haralson III, MD, MBA haralson@aaos.org

2 North Carolina Medical Society 2008 Problem 1 QUALITY 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

3 North Carolina Medical Society 2008 Orthopaedics Fractured hips (9 parameters) –Prophylactic antibiotics –Prophylactic thromboembolism medications –Proper lab work Coagulation profile

4 North Carolina Medical Society 2008 Orthopaedics Received appropriate regimen 22%

5 North Carolina Medical Society 2008 Problem 2 COST 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

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8 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

9 North Carolina Medical Society 2008 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

10 North Carolina Medical Society 2008 Pros Reduced practice variations Catalyzes investment in HIT Incentives for preventative care Incentives for health plan competition

11 North Carolina Medical Society 2008 Cons Process vs. Outcomes –We want outcomes –Process can be a surrogate for outcomes (audit) –Outcomes point out a problem but does not identify the source

12 North Carolina Medical Society 2008 Cons No good way to risk adjust –Especially in surgery –Co-morbidities –Patient non-compliance –Cultural and religious differences –Statins example

13 North Carolina Medical Society 2008 Cons Attribution –Care provided by multiple providers Fractured hip with cardiovascular disease Fractured hip with osteoporosis Assigning measures to a specialty

14 North Carolina Medical Society 2008 Rebuttal With large population studies, risk adjustment and attribution are not necessary

15 North Carolina Medical Society 2008 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)

16 North Carolina Medical Society 2008 Cons Increase 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

17 North Carolina Medical Society 2008 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

18 North Carolina Medical Society 2008 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

19 North Carolina Medical Society 2008 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)

20 North Carolina Medical Society 2008 Cons Effeciency measures Cost / quality = Efficiency Cost = episodes of care (groupers) Cost (bad number) / Quality (bad number) = Nirvana (efficiency)

21 North Carolina Medical Society 2008 Cons Errors in reporting –Wash. U. experience –Black boxes –Transparency –Lack of appeal mechanism

22 North Carolina Medical Society 2008 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)

23 North Carolina Medical Society 2008 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

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26 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”

27 North Carolina Medical Society 2008 Theoretical Con “Rare things don’t happen very often, but they do occur” –Harold Boyd, MD You must not forget to look for Zebras

28 North Carolina Medical Society 2008 PQRI, 2008 Voluntary All of 2008 Incentives are the same (1 ½%) (sort of)

29 North Carolina Medical Society 2008 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/https://nppes.cms.hhs.gov/NPPES/ Paid by pay number

30 North Carolina Medical Society 2008 Surgical Measures Prophylactic antibiotics within 1 hour of surgery Use of a first or second generation cephaolsporin Discontinue antibiotics within 24 hours Thromboembolic prophylaxis

31 North Carolina Medical Society 2008 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 exerciseCounseling on use of vitamin D and exercise

32 North Carolina Medical Society 2008 4 New Measures Adoption of Health IT Adoption of E-prescribing Diabetic vascular exam Diabetic foot ulcer exam

33 North Carolina Medical Society 2008 Other Possibilities Medication reconciliation Disease modifying anti-rheumatic drug therapy in rheumatoid arthritis Inquiry regarding tobacco use Advising smokers to quit.

34 North Carolina Medical Society 2008 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

35 North Carolina Medical Society 2008 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

36 North Carolina Medical Society 2008 Resources www.cms.hhs.gov/pqri www.aaos.org/pqri Articles Webinar Worksheets Step by step instructions

37 North Carolina Medical Society 2008 Latest Concepts Care 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.

38 North Carolina Medical Society 2008 Care Coordination Medical Home Does not have to be a PC

39 North Carolina Medical Society 2008 Latest Concepts Composite Measures Combination of several measures like McGlynn

40 North Carolina Medical Society 2008 Summary Pros - short list (quality and cost) –Rewards are possibly great –Consequences of not doing it are disastrous

41 North Carolina Medical Society 2008 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

42 North Carolina Medical Society 2008 Prediction 1. Quality reporting is here to stay 2. Eventually it will not be “P4P”, it will be “Report to Survive”

43 North Carolina Medical Society 2008 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

44 North Carolina Medical Society 2008 Thank You


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