Download Pros and Cons of P4P - North Carolina Medical Society

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
– Cost and quality have an inverse relationship
North Carolina Medical Society
2008
Orthopaedics
• Fractured hips (9 parameters)
– Prophylactic antibiotics
– Prophylactic thromboembolism
medications
– Proper lab work
• Coagulation profile
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2008
Orthopaedics
Received appropriate regimen
22%
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
North Carolina Medical Society
2008
North Carolina Medical Society
2008
North Carolina Medical Society
2008
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
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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2008
Pros
•
•
•
•
Reduced practice variations
Catalyzes investment in HIT
Incentives for preventative care
Incentives for health plan
competition
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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
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
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2008
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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2008
Rebuttal
With large population studies,
risk adjustment and
attribution are not
necessary
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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)
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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
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
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
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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)
North Carolina Medical Society
2008
Cons
Effeciency measures
Cost / quality = Efficiency
Cost = episodes of care (groupers)
Cost (bad number) / Quality (bad number) =
Nirvana (efficiency)
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2008
Cons
• Errors in reporting
–Wash. U. experience
–Black boxes
–Transparency
–Lack of appeal mechanism
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)
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
North Carolina Medical Society
2008
North Carolina Medical Society
2008
North Carolina Medical Society
2008
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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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
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2008
PQRI, 2008
• Voluntary
• All of 2008
• Incentives are the same
(1 ½%) (sort of)
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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/
• Paid by pay number
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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
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2008
10 Orthopaedic Measures
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•
•
•
•
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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
• Adoption of Health IT
• Adoption of E-prescribing
• Diabetic vascular exam
• Diabetic foot ulcer exam
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2008
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?
• 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
• 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
www.cms.hhs.gov/pqri
www.aaos.org/pqri
Articles
Webinar
Worksheets
Step by step instructions
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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.
North Carolina Medical Society
2008
Care Coordination
Medical Home
Does not have to be a PC
North Carolina Medical Society
2008
Latest Concepts
Composite Measures
Combination of several
measures like McGlynn
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2008
Summary
• Pros - short list (quality and
cost)
–Rewards are possibly great
–Consequences of not doing it
are disastrous
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
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”
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
North Carolina Medical Society
2008
Thank You
North Carolina Medical Society
2008