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

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pros and cons of the quality initiative

Pros and Cons of The Quality Initiative

R H Haralson III, MD, MBA

haralson@aaos.org

problem 1 quality
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

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orthopaedics
Orthopaedics
  • Fractured hips (9 parameters)
    • Prophylactic antibiotics
    • Prophylactic thromboembolism medications
    • Proper lab work
      • Coagulation profile

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orthopaedics4
Orthopaedics

Received appropriate regimen

22%

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problem 2 cost
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

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alphabet soup of the quality initiative
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

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slide9
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

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slide10
Pros
  • Reduced practice variations
  • Catalyzes investment in HIT
  • Incentives for preventative care
  • Incentives for health plan competition

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slide11
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

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slide12
Cons

No good way to risk adjust

  • Especially in surgery
  • Co-morbidities
  • Patient non-compliance
  • Cultural and religious differences
  • Statins example

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slide13
Cons

Attribution

  • Care provided by multiple providers
    • Fractured hip with cardiovascular disease
    • Fractured hip with osteoporosis
    • Assigning measures to a specialty

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rebuttal
Rebuttal

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

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slide15
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)

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slide16
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

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slide17
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

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slide18
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

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slide19
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)

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slide20
Cons

Effeciency measures

Cost / quality = Efficiency

Cost = episodes of care (groupers)

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

Nirvana (efficiency)

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slide21
Cons
  • Errors in reporting
    • Wash. U. experience
    • Black boxes
    • Transparency
    • Lack of appeal mechanism

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slide22
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)

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slide23
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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theoretical con
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”

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theoretical con27
Theoretical Con
  • “Rare things don’t happen very often, but they do occur”
    • Harold Boyd, MD
  • You must not forget to look for Zebras

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pqri 2008
PQRI, 2008
  • Voluntary
  • All of 2008
  • Incentives are the same (1 ½%) (sort of)

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pqri 200829
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

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surgical measures
Surgical Measures
  • Prophylactic antibiotics within 1 hour of surgery
  • Use of a first or second generation cephaolsporin
  • Discontinue antibiotics within 24 hours
  • Thromboembolic prophylaxis

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10 orthopaedic measures
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

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4 new measures
4 New Measures
  • Adoption of Health IT
  • Adoption of E-prescribing
  • Diabetic vascular exam
  • Diabetic foot ulcer exam

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other possibilities
Other Possibilities
  • Medication reconciliation
  • Disease modifying anti-rheumatic drug therapy in rheumatoid arthritis
  • Inquiry regarding tobacco use
  • Advising smokers to quit.

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how do i report
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

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slide35
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

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resources
Resources

www.cms.hhs.gov/pqri

www.aaos.org/pqri

Articles

Webinar

Worksheets

Step by step instructions

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latest concepts
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.

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care coordination
Care Coordination

Medical Home

Does not have to be a PC

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latest concepts39
Latest Concepts

Composite Measures

Combination of several measures like McGlynn

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summary
Summary
  • Pros - short list (quality and cost)
    • Rewards are possibly great
    • Consequences of not doing it are disastrous

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summary41
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

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prediction
Prediction

1. Quality reporting is here to stay

2. Eventually it will not be

“P4P”,

it will be

“Report to Survive”

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admonishment
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

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slide44

Thank You

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