Pros and cons of the quality initiative
Download
1 / 44

pros and cons of the quality initiative - PowerPoint PPT Presentation


  • 345 Views
  • Uploaded on

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

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'pros and cons of the quality initiative' - Patman


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript

Problem 1 quality l.jpg
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

North Carolina Medical Society 2008


Orthopaedics l.jpg
Orthopaedics

  • Fractured hips (9 parameters)

    • Prophylactic antibiotics

    • Prophylactic thromboembolism medications

    • Proper lab work

      • Coagulation profile

North Carolina Medical Society 2008


Orthopaedics4 l.jpg
Orthopaedics

Received appropriate regimen

22%

North Carolina Medical Society 2008


Problem 2 cost l.jpg
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

North Carolina Medical Society 2008




Alphabet soup of the quality initiative l.jpg
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

North Carolina Medical Society 2008


Slide9 l.jpg
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

North Carolina Medical Society 2008


Slide10 l.jpg
Pros

  • Reduced practice variations

  • Catalyzes investment in HIT

  • Incentives for preventative care

  • Incentives for health plan competition

North Carolina Medical Society 2008


Slide11 l.jpg
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

North Carolina Medical Society 2008


Slide12 l.jpg
Cons

No good way to risk adjust

  • Especially in surgery

  • Co-morbidities

  • Patient non-compliance

  • Cultural and religious differences

  • Statins example

North Carolina Medical Society 2008


Slide13 l.jpg
Cons

Attribution

  • Care provided by multiple providers

    • Fractured hip with cardiovascular disease

    • Fractured hip with osteoporosis

    • Assigning measures to a specialty

North Carolina Medical Society 2008


Rebuttal l.jpg
Rebuttal

With large population studies, risk adjustment and attribution are not necessary

North Carolina Medical Society 2008


Slide15 l.jpg
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)

North Carolina Medical Society 2008


Slide16 l.jpg
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

North Carolina Medical Society 2008


Slide17 l.jpg
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

North Carolina Medical Society 2008


Slide18 l.jpg
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

North Carolina Medical Society 2008


Slide19 l.jpg
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)

North Carolina Medical Society 2008


Slide20 l.jpg
Cons

Effeciency measures

Cost / quality = Efficiency

Cost = episodes of care (groupers)

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

Nirvana (efficiency)

North Carolina Medical Society 2008


Slide21 l.jpg
Cons

  • Errors in reporting

    • Wash. U. experience

    • Black boxes

    • Transparency

    • Lack of appeal mechanism

North Carolina Medical Society 2008


Slide22 l.jpg
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)

North Carolina Medical Society 2008


Slide23 l.jpg
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

North Carolina Medical Society 2008




Theoretical con l.jpg
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”

North Carolina Medical Society 2008


Theoretical con27 l.jpg
Theoretical Con

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

    • Harold Boyd, MD

  • You must not forget to look for Zebras

North Carolina Medical Society 2008


Pqri 2008 l.jpg
PQRI, 2008

  • Voluntary

  • All of 2008

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

North Carolina Medical Society 2008


Pqri 200829 l.jpg
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

North Carolina Medical Society 2008


Surgical measures l.jpg
Surgical Measures

  • Prophylactic antibiotics within 1 hour of surgery

  • Use of a first or second generation cephaolsporin

  • Discontinue antibiotics within 24 hours

  • Thromboembolic prophylaxis

North Carolina Medical Society 2008


10 orthopaedic measures l.jpg
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 exercise

North Carolina Medical Society 2008


4 new measures l.jpg
4 New Measures

  • Adoption of Health IT

  • Adoption of E-prescribing

  • Diabetic vascular exam

  • Diabetic foot ulcer exam

North Carolina Medical Society 2008


Other possibilities l.jpg
Other Possibilities

  • Medication reconciliation

  • Disease modifying anti-rheumatic drug therapy in rheumatoid arthritis

  • Inquiry regarding tobacco use

  • Advising smokers to quit.

North Carolina Medical Society 2008


How do i report l.jpg
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

North Carolina Medical Society 2008


Slide35 l.jpg

  • 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

North Carolina Medical Society 2008


Resources l.jpg
Resources

www.cms.hhs.gov/pqri

www.aaos.org/pqri

Articles

Webinar

Worksheets

Step by step instructions

North Carolina Medical Society 2008


Latest concepts l.jpg
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.

North Carolina Medical Society 2008


Care coordination l.jpg
Care Coordination

Medical Home

Does not have to be a PC

North Carolina Medical Society 2008


Latest concepts39 l.jpg
Latest Concepts

Composite Measures

Combination of several measures like McGlynn

North Carolina Medical Society 2008


Summary l.jpg
Summary

  • Pros - short list (quality and cost)

    • Rewards are possibly great

    • Consequences of not doing it are disastrous

North Carolina Medical Society 2008


Summary41 l.jpg
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

North Carolina Medical Society 2008


Prediction l.jpg
Prediction

1. Quality reporting is here to stay

2. Eventually it will not be

“P4P”,

it will be

“Report to Survive”

North Carolina Medical Society 2008


Admonishment l.jpg
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

North Carolina Medical Society 2008


Slide44 l.jpg

Thank You

North Carolina Medical Society 2008


ad