Incentives for Enhancing Stroke Care Sandra M. Schneider, MD (Chair) Larry B. Goldstein, MD (Co-Chair) James G. Adams, MD Kenneth L. DeHart, M.D Michael D. Hill, MD Andrew M. Demchuk, MD Anthony Furlan, MD Michael T. Rapp, MD, JD Joseph P. Wood, M.D., J.D.

Principles & Caveats  Broad-based approach, but  No representation from –Third party payers –Hospital administrators –Primary care providers –Radiologists  Lessons from experience with acute thombolysis

Incentives Matrix Medicolegal Financial Medical/Scientific Administrative PayersHealthSystemsNeurologists Emergency Physicians DomainsDomainsDomainsDomains Stakeholders

Emergency Physicians Administrative  Over 90% of ED directors perceive their department is either at or over capacity  American Hospital Association- 62% of EDs are at or over capacity  Point prevalence study done on a typical spring evening found –1.1 patients per treatment space –4.2 patients per RN –9.7 patients per physician  Nearly 70% of emergency department care is delivered in ‘off-hours’  Stress in the system for delivery of optimal care

Emergency Physicians tPA Experience  Medical/ scientific issues perceived as unresolved  Lack of consultative support for acute stroke treatment (radiological, neurological) is viewed as the most significant barrier  Lack of systems support  Medicolegal risk

Emergency Physicians Incentives  Improved consultative resources –Neurology/ radiology –Regional consultative practices Telemedicine/ teleradiologyTelemedicine/ teleradiology –Poison Control Center model  Support development of primary stroke care centers & care systems –Care pathways/ protocols  Address staffing issues –Hospitals/ health care systems –Payers

Incentives Matrix Medicolegal Financial Medical/Scientific Administrative PayersHealthSystemsNeurologists Emergency Physicians DomainsDomainsDomainsDomains Stakeholders

Neurology Administrative  Limited numbers of neurologists who are concentrated in major metropolitan areas  Many neurologists sub-specialize and may not regularly care for stroke patients –No more than 50% of American neurologists have given IV tPA for acute stroke  General neurologists practice primarily in an outpatient setting –Need to be available to be called during a busy clinic, often off-site

Neurology Medical/ Scientific/ Medicolegal: tPA Example  Debate about optimal patients for treatment  In one survey, less than one third (30%) of neurologists found the evidence for tPA efficacy “very convincing”  Many felt the drug was “too risky”  62% were “very concerned” about ICH  Medicolegal concern Neurology 1998;50: Stroke 2001;32:

Neurology Financial  Economics of clinical practice dictate a tightly scheduled day  Evaluation of a stroke patient can take several hours  Limited financial reimbursement is a disincentive to leaving a crowded office to provide emergency consultative services  Telephone consultation –Consultants are legally liable for advice given over the telephone –There is no financial reimbursement for telephone consultation  Neurologists frequently interpret radiographic studies such as CT scans to guide treatment –They are rarely financially reimbursed for these activities

Neurology Incentives  Training of all new neurologists in stroke care –Paradigm shift  Continue to address medical and scientific concerns  Update current CPT coding with appropriate RVUs for acute stroke, including thrombolytic therapy  Reimbursement for telephone/telemedicine consultations and for interpretation of acute stroke imaging studies by neurologists  Clarify medicolegal liabilities related to acute stroke interventions, including telephone consultations

Incentives Matrix Medicolegal Financial Medical/Scientific Administrative PayersHealthSystemsNeurologists Emergency Physicians DomainsDomainsDomainsDomains Stakeholders

Health Systems  Support of health systems is critical  Because there may be different payers for acute and long-term care, even if an acute treatment is cost-effective from a societal standpoint, it may increase the costs to those providing the treatment that is not reimbursed (disincentive)  Currently no stroke CMS quality indicators  Little incentive to support stroke QI initiatives

Health Systems Incentives  Studies show that having an organized system of care shortens LOS, decreases complications and can reduce costs  CMS will likely reintroduce stroke indicators  Programs to identify stroke centers are being discussed

Incentives Matrix Medicolegal Financial Medical/Scientific Administrative PayersHealthSystemsNeurologists Emergency Physicians DomainsDomainsDomainsDomains Stakeholders

Medicolegal  Malpractice –Violation of the accepted standard of care resulting in harm to a patient  In court, opinions about the standard of care are provided by one or more experts  The starting point for litigation is often a bad outcome (because the patient had a stroke)

Medicolegal tPA Example  Failure to administer –Had it been used, the outcome would have been the elimination of the patient’s neurological deficits –Hard to prove scientifically, but easy to establish in a court of law since it may merely require the opinion of a qualified witness  The administration was either not indicated or improperly administered –Hemorrhage or perhaps simply failure to be cured

Fertile Field for Malpractice Litigation  Uncertainty, lack of familiarity, lack of support  Popular press, magazines, and newspaper stories have sometimes overstated the therapeutic potential  Advertisements and websites of malpractice attorneys highlight the “alarmingly low” use of tPA for patients with acute stroke, “especially for African Americans.” 1  “If you suspect that a loved one should have received tPA but did not, or that tPA was administered improperly, it may be important to contact an attorney.” 2  “If you suspect that a loved one should have received tPA but did not, or that tPA was administered improperly, it may be important to contact an attorney.” 2 (1) (2)

Reducing Medicolegal Risk  Appropriate consultative support  Institutional evidence-based policies for the use of a treatment  Follow accepted guidelines or policy statements by professional organizations

Incentives Matrix Medicolegal Financial Medical/Scientific Administrative PayersHealthSystemsNeurologists Emergency Physicians DomainsDomainsDomainsDomains Stakeholders

Financial  Facilities reimbursed by governmental payers based on a Diagnosis Related Grouping (DRG) methodology –Largely reflects overhead costs calculated from “case data” with little recognition of the expense of new therapies  Commercial payers typically compensate on a “per diem” basis, with denied payment inconsistency  Physician payment based on CPT codes (E&M Codes) –CPT code for IV tPA for acute stroke (37195), the work RVU is 0 –Concurrent care may not be reimbursed (disincentive to team approach)  Financial support for stroke systems lacking

Payers Incentives to Improve Care  Recognition of the added value of supporting stroke care systems –Support medical leadership and system analysis (QI programs)  Reimbursement must reflect the increased costs to institutions providing new interventions  CPT-Code revision –Redefine existing codes (37195) –Develop specific new codes for acute stroke care –Advocate against restrictions based on concurrency of care –Support telephone consultation (codes exist, not paid)  Support telephone consultative centers (Poison Center Model)  Patient & professional groups need to advocate for change

The Bottom Line

Summary of Incentives -1  Support the development and maintenance of stroke care systems  Provide acute stroke consultative support (especially neurological and radiological expertise) for ED physicians and non-specialist care providers through in-hospital protocols and systems approaches, including telemedicine consultation and teleradiology as appropriate

Summary of Incentives -2  Develop a coordinated stroke reimbursement strategy involving patient advocates and professional organizations  Define medicolegal issues in order to reduce physician liability risk related to the provision of innovative acute stroke care  Support outcomes assessment programs to inform quality improvement efforts and dissemination of best practices

Summary of Incentives- 3  Assure that appropriate education is conducted and that consensus is achieved as new therapies are introduced. Educational priorities include emergency caregivers, neurologists and nursing staff  Provide forums for constructive dialog among emergency physicians, neurologists and other key stroke care providers  Continue to refine and advance the level of stroke care through clinical research

Incentives Matrix Emergency Physicians NeurologistsHealthSystemsPayersAdministrative Medical/Scientific Financial Medicolegal DomainsDomainsDomainsDomains Stakeholders