It is not often that an organization like McKinsey,
high-priced heavy duty business consultants, would look to the
non-profit world as a model for business innovation. In “The
ergonomics of innovation
”
two McKinsey consultants analyze what made the IHI 100,000 Lives
Campaign so successful. The point is not that the campaign worked,
but the techniques which made it work. To read their analysis
offers a different way of thinking about innovation in any setting.
Making the right thing to do the easy thing to do is key to having
a real impact. Blending new ideas with old, limiting the burden
of thought and action, specificity of goals, naming the problem,
using a hard count, applying “affordances” are all
highlighted as techniques that foster the spread of innovation.
This is a really interesting look at how pure business consultants
see what we talk about in terms of “using engaging methods” to
engage with physicians. Highly recommended to stimulate thinking
about how to proceed to implement the principles of UFT-A and
more.
The costs associated with ‘never events’ will
no longer be paid by Medicare and many other
payors. What will the impact of no payment
for never events
actually look like? In a case study approach to the reality of
these issues, and the clinical complexities they present, Caroline
Blankenship, in a recent issue of the Health
Lawyer,
not only factualizes clinical circumstances, but calculates the
financial
impact on the hospital and offers practical suggestions to avoid
trouble in the first place. Interesting reading. Please note
the following with regard to the PDF: Copyright 2008 American
Health Lawyers Association, Washington, D.C.Reprint permission
granted.
Further reprint requests should be directed to
American Health Lawyers Association
1025 Connecticut Avenue, NW, Suite 600
Washington, DC 20036
(202) 833-1100
For more information on Health Lawyers content, visit us at
www.healthlawyers.org
The organized medical staff has a unique role in
assuring the quality of care in hospitals. Yet the volunteer
medical staff members are under unprecedented pressures which
inhibit their willingness to take on tasks they traditionally
have performed for free – whether medical staff leadership,
service on committees, or on-call and indigent care coverage.
Now, there is some data showing that throughout the country,
there is an emerging bifurcation into alternate models of medical
staff-hospital relationships. (See, Casalino et al, “Hospital-Physician
Relations: Two Tracks And The Decline of the Voluntary Medical
Staff”, Health Affairs (Sept 2008).
Where in the era of post-failed Clinton health reform, hospitals
bought primary care practices and then had to unload them, more
and more hospitals today are acquiring specialist practices and
employing specialist physicians. Equally present are the settings
in which members of the medical staff go into competition with
the hospital and cease to attend there as much as they used to,
while they own and develop ambulatory surgery centers, imaging
facilities and even whole specialty hospitals. What is the significance
of this for medical staff governance and quality surveillance?
These changes in organizational arrangements really ought to
have little meaning to the functioning of the organized medical
staff in relationship to the hospital board and administration
with regard to its principal responsibilities for quality. The
medical staff members, whether employed or independent or more
typically a mix, still have a unique role in the hospital.
Some commentators have taken the position that
the organized
medical staff is obsolete if not moribund.
We believe they may be wrong; although it is becoming increasingly
important to consider carefully just what the function of the
medical staff ought to be in the highest quality environments.
If 20% of the medical staff is responsible for 80% of the hospital
admissions, then who should be considered Active Staff with governance
authority to make the rules for the interrelationships among
all physicians? Who should define the quality culture for physicians?
If the hospital employs the physicians and mandates their participation
in activities that fundamentally do not interest them, what will
be the outcome for patients? If the medical executive committee
is focused on internecine warfare, endovascular food-fights and
not how many hearses leave the hospital and why, what will the
hospital do without a medical staff on whom it can rely to create
a high quality environment? We think these are essential questions
which merit the attention of hospitals, their boards and medical
staff members. We do not believe that employment of medical staff
members ensures an engaged medical staff which will work well
on quality issues. We think that the current moment in quality
policy and demand for demonstrated hospital quality performance
offers an unprecedented opportunity to reinvigorate the role
of the medical staff around issues that really matter.
Since the inception of this website we have highlighted
the inexorable movement of fraud enforcers to direct targeting
of quality problems as fraud. (See, link to (5) #5, #8, #13,
#27) When the AHLA and the OIG published joint guidance to hospital
boards on their fiduciary responsibilities
for quality it was clearly game on! We have highlighted
the quality-compliance nexus
in the past as well. The rules of the game have so intensified,
however, that we now believe that it can
be said that a major goal for all health care providers in the
21st century will be “Avoiding
Quality Fraud”.
Our article in Trustee magazine is directed to hospital
boards, but has meaning to everyone in health care. The increasing
volume of quality data reporting, implied statements about quality
in claims filed, and flat out false claims liability lurk. It
is significant that hospital quality data reporting has been
targeted by the OIG in the 2009
Work Plan as
a topic of attention.
In her first participation in the teleconference series offered
by The Reinertsen Group, Alice elucidates the varieties of these
frauds and their pitfalls. In this 90 minute presentation she
offers practical tips for avoiding quality fraud in a dialogue
with Jim and Jamie Orlikoff. The teleconference is available
for
sale and download.
The search for a new payment model to propel and
support better quality of care continues with even greater fervor,
given the economic crisis and rising health care costs. Meredith
Rosenthal, a member of the PROMETHEUS Payment® Design Team, but
also one of the premier scholars on pay-for-performance, looks
at efforts to move beyond P4P in her article “Beyond Pay
for Performance – Emerging Models of Provider-Payment Reform.” NEJM
359:12 (September 18, 2008) 1197-1200. She offers a nice chart
which compares the general approaches of incremental reform (no
pay for “never events”), primary care payment reform
(medical home), episode-based payment (PROMETHEUS and Geisinger)
and shared savings models (Medicare Group Practice Demo). She
concludes that there are fundamentally no “new” payment
methods, and that economic theory (and she is an economist) holds
that mixed payment models will work better than any one approach.
This leaves the door open to new variants to emerge. It is fair,
however, to observe, based on this review, that the PROMETHEUS
Payment® Model offers the most robust new payment vehicle
available, today.
The Medical Home, sometimes
referred to as the “Patient-centered Medical
Home”, despite
sounding like a website or new kind of residential facility,
is gaining traction as a route to reorganizing the delivery of
care to certain populations. Finding its foundation 40 years
ago in pediatrics, it is now touted as the answer for primary
chronic care improvement as well as payment. A recent search
for those who are very successful with these programs has led
Arnold Milstein MD, to draw some interesting conclusions about
what makes for a “Medical
Home Run”. Unwavering commitment
to keeping patients out of the hospital
is key. By the same token, though, a recent issue of Health Affairs
has looked at a variety of controversies and claims regarding
the medical home, from differences in its definition
and components,
to whether those who might be most interested in offering the
medical home model in fact have the infrastructure to do so.
Rittenhouse, Casalino, et al, found that large
medical groups were better prepared
with elements of infrastructure alone (e.g., patient reminders,
physician feedback, electronic
records
and more) to offer this approach to organizing care delivery,
but even they were not routinely ready to do all that the medical
home model promises.
In reviewing the claims for this model, it appears there are
two movies currently playing in local theaters: Medical
Home: The Clinical Movie --- which is about organizing care delivery
to be sure patients can rely on a single practice to be accountable
for and responsive to their needs across the continuum of care
delivery; and then there is Medical Home: The Payment
Movie.
Here the story is yet another transitional approach to curing
the dissymmetry between high quality, patient-centric clinical
processes and current payment models. Medical Home: The Payment
Movie seeks additional dollars to pay for the infrastructure
which makes coordination of care possible. In fact, were additional
payment to be made for intrastructure alone, there is no guarantee
any change in quality would result. Still, it is indisputable
that it costs money to implement infrastructure that makes a
medical home possible --- to use non-physicians to help engage
patients in their own care, maintain registries and other electronic
data to foster clinically important interactions with patients
and to keep tabs on the care they are getting.
The PROMETHEUS Payment® Model is highly consistent
with the Clinical Movie script and is even better than the transitional,
small-additions-to-current-payments storyboard of the Payment
Movie. Also intriguing is the application of the medical home
clinical approach to other types of care, like hematology-oncology.
Those physicians are losing their business model based on drug
payments and ought be paid for the care and coordination that
are the core of what they do. Infectious disease physicians have
similar issues, as do rheumatologists treating arthritics. The
basic premise of the Clinical Movie is not only viable for primary
care. It deserves consideration elsewhere. Elements of it are
consistent with UFT-A principles as well.
The Institute for Healthcare Improvement (IHI)
offered the first program on Engaging Physicians in A
Shared Quality Agenda in February, 2007. IHI has offered the program
four times; and the next time will be April 21-23, 2009, in Chicago.
This program has consistently sold out six weeks in advance.
Under the leadership of Jim, we are joined by two other faculty
members for what has been a two day program. Now, because of
the intense interest and burgeoning need for more tools to engage
physicians, IHI is adding an optional additional half day, led
by Alice and Jim, that will focus on the role of medical staff
bylaws in advancing quality and associated controversies with
hospital payment to physicians around quality including Stark
and gainsharing, as well as compensating physicians for quality
within their own groups. Folks who have attended the earlier
IHI programs can register for the half day as a stand alone as
well.
If you look
at the agenda, you will see how unique it is, interweaving
principles of clinical process standardization, with the physician
business case for quality, the use of compacts to change culture,
with an understanding of permissible boundaries for financial
relationships between hospitals and physicians under fraud and
abuse, stories of what works…and more. We have revised
the session in multiple ways to make it even better based on
attendee comments. Jim and Alice are also available
to present their parts of this program outside
of the IHI context, customized for specific organizations in
shorter sessions. The driving principle
here is that hospitals will fare far better if they organize
more around engaging effectively in the physicians’ quality
agenda. The principals, methods, and framework are applicable
to other kinds of health care providers and in other settings.
The background for the program is now available in a formal IHI
Innovation Series White Paper which
provides the framework and the reasoning behind its six components,
along with resources
and tools to make physician engagement real.
Gainsharing ---- where hospitals give to cooperating
physicians some of the savings from cost reduction steps ---
has been cited as a potential quality enhancing technique which
also can bond physicians with hospitals. Gainsharing was the
basis for a fraud and abuse settlement with the Paracelsus Hospital
Company back in 1983 when DRGs were first implemented. The OIG
has now approved about a dozen of these programs, focused
around procedurally based services. Labeled
as efforts to standardize care, the approved programs have multiple
bell-and-whistle safeguards against reducing services to patients,
but all of approved programs are short-lived (one year in length).
While gainsharing may serve some purposes in the short-run, it
has limited applicability and is not at its essence about quality.
By contrast, as part of the 2009 Medicare Fee Schedule, CMS has
proposed regulations to govern both gainsharing (“shared
savings”) programs and quality incentive payment programs
under the Stark statute. Protection will be available only to
programs between hospitals and physicians. You can read Alice’s
comments to CMS on the proposed quality
incentive payment regulations,
in which she distinguishes the risks in these types of programs
and calls for greater flexibility in the context of incentive
payments.
Under the auspices of the Office of the Governor,
North Carolina has launched a statewide program to implement
evidence-based care guidelines for five chronic conditions. Health
plans and providers have agreed to provide consistent services
to patients regardless of their health insurance coverage. The
initiative was
apparently a year in its development. Involving collaborative
efforts among
physicians, quality experts and insurers, it is part of an
effort “to
fundamentally restructure the delivery of health care in North
Carolina” in accordance with best practices. Interestingly,
none of the press stories reveal the chronic, traditional anxiety-driven
provider arguments with respect to potential malpractice liability
which could emerge from the adoption of these guidelines. Perhaps
we are finally getting to the enlightened understanding that
doing the right thing will actually potentially prevent both
malpractice claims and exacerbated illnesses --- the point
of standardizing care in the first place.
The fundamental principle of UFT-A is that if all
the members of the care team collaborate in accordance with the
same iterations of the best science available, the whole system
will work better. In an interesting survey of The
Role of Nurses in Hospital Quality Improvement,
the Center for Health System Change elucidates the tensions in
the accreting volume of quality improvement work expected of
hospitals, as well as the need for nurse engagement while care
at the bedside is also a critical challenge in light of staffing
shortages. The role of culture and leadership in supporting nurse
involvement was cited, along with the results that came when
nurses were supported in their engagement. As Jim says on his
website, “If
you really want it done right, regularly, get a nurse involved.”
For UFT-A principles to work, the whole care team should be engaged
at their highest and best uses, in accordance with the clinical
guidelines that drive the enterprise.
Pay for performance is sweeping the country. Despite
equivocal data as to success and impact, most payors regard it
as inevitable, and most physicians are resigned to its arrival
soon at a theater near them, if they are not already confronting
it. Medicare’s ‘pay for quality reporting’ initiative
really is “pay for whatever I did” because it is
the completion of the form, not the quality of the care, which
gets the payment bonus. CMS was met with a tepid enrollment of
17% of potential participants. And that program is not
limited to physicians, but includes other non-physician practitioners
as well. While these initiatives continue to be touted as ‘payment
reform,’ on the other side of the ledger, both CMS and
many health insurance programs are adopting no pay for no performance
programs by denying payment for never events -- mishaps of such
an egregious nature that they never should have occurred in the
first place, in essence no pay for no performance. Hospital associations
have stepped forward to say their members will not bill for such
events including wrong site surgeries, retention of foreign objects
after surgery, death or disability associated with wrong type
blood transfusions. First promulgated by the National
Quality Forum in 2002, the list of the initial 27 “never events” is
not without controversy, since a range of the conditions cited
include matters which may have been present on admission (decubitus
ulcers). Medicare has proposed to add conditions to those it
already requires to be reported and on which it will not pay
for the care devoted to treatment of the event or complication.
There is some question as to whether this approach will be applied
to physicians. In the PROMETHEUS Payment® model, a readmission
for something related to myocardial infarction within thirty
days of discharge is considered a potentially avoidable complication
for both the physician and hospital.
The challenge of engaging physicians in quality
initiatives at the hospital often falls most heavily on the shoulders
of the medical leadership in the C-suite, whether the chief medical
officer or the VPMA or the chief of staff. In our article directed
to these folks, “Finding
Common Cause in Quality: Confronting The Physician Engagement
Challenge”, we dispute
the metaphor offered by Jeff
Goldsmith of the hospital-physician engagement continuum as a
coral reef of predators and prey. From our continuing work with
IHI and medical staffs and hospitals around the country, we continue
to hold the firm belief that enormous strides can be made for
better patient care and more activated physicians, when physicians
are seen as the hospital’s true partners and not mere customers.
With her study of the current identified effects
of P4P, traditional compensation models within physician groups,
survey of groups
which do compensate on quality and consideration
of the legal issues in doing so, Alice opened the door to focusing
on this aspect of motivating quality improvement. In her article, “Compensation
for Quality: The Next Inevitable Step”, she not only makes
the point that quality will never reach optimal levels if physicians
do not have consistent payment incentives within their groups,
but she affirmatively calls for more information about organizations
which do pay their physicians for quality. It is hard to believe
that only 14 groups around the country, and most of them very
large multi-specialty organizations, are experimenting with these
efforts. Since the article was published she has received information
from 5 more groups whose data tracks directly to her earlier
findings. The phenomenon is increasing. But some have been toiling
quietly at this work for longer than any published reports would
reveal. If your physician group or system compensates your physicians
in any measure for their quality performance or based on their
quality performance, please contact us at info@uft-a.com with
your story.
First convened in December
2004 as a disparate group of experts intending to design a new
payment model, PROMETHEUS
Payment® Inc., has now been awarded a $6.4
million grant from the Robert Wood Johnson
Foundation, to develop a scorecard, refine the concepts and most
importantly test the program in
four pilot sites across the country. Having modeled its first
Evidence-informed Case Rates® for actual implementation
beginning in 2009, the results are quite stunning. In her plain
language article, “Making
PROMETHEUS Payment® Rates
Real: Ya’Gotta’ Start Somewhere” Alice
explains the methodology of constructing the rates. First, she
elucidates
how the Design Team took into account its clear understanding
that physicians would be suspicious of rates built on claims
data. There are five specific financial cushions built into the
rates. The result is that the care for a controlled non-insulin
dependent diabetic, whose care comes primarily from a physician
office, would be paid based just on the claims data at $311 a
year; but, under the PROMETHEUS system, the same patient’s
care would be eligible for $2329 to the physician!!! At the same
time, what is most remarkable is that this approach to the broad
problem of delivering science based diabetes care would save
the system represented in just the database we are using and
this one condition, more than $340 million. This is a very powerful
reason to move to the PROMETHEUS Payment® model. Similar
results are emerging for the other conditions we will address
initially as well. The more important hidden message in the article,
though, is whether our specific program is implemented is not
the issue. Throughout the American healthcare system, we are
spending extraordinary amounts of money on potentially avoidable
complications, while we are not paying providers enough to do
what needs to be done to prevent those complications in the first
place. Thinking about which services the PROMETHEUS model considers
to be potentially avoidable, and then analyzing how to avoid
them, is a good way to approach how to organize clinical service
delivery for better results with greater efficiency. PROMETHEUS
Payment® Inc. is looking for provider-plan combos who want
to step up and try implementing some of the ECRs® without
being a formal pilot site (which requires a three year commitment
to use all the ECRs® and participate in evaluation. If you
would like to explore that possibility, please contact us at PROMETHEUS@uft-a.com.
Be careful
what you measure and reward is a longstanding truism
in quality measurement, because the subjects of the reports
will work to get good scores. As
a result, the risk that other problems will be ignored increases.
This phenomenon has recently produced potential over-diagnosis
and consequent over-prescribing in response to CMS
measures.
When payment is linked to specific activities, those activities
will
be done to be assured of achieving the payment. That is the point
of incentives. UFT-A takes a different approach. While one of
the tenets is to fix accountability at the locus of control,
linking specific accountable behaviors to specific additional
payments or reductions, is like fee-for-service in drag – it
simply motivates the measured behavior in isolation and nothing
more, unless composite scores are used, UFT-A, and now the PROMETHEUS
Payment® model, both stand for the proposition that paying
the right amount for the right services at the right time, with
no single behavior generating additional or reduced payment is
a far better way to go.
For well more than thirty
years, the literature has confirmed that the single most powerful
risk management technique is a good doctor-patient relationship.
Patients do not sue the doctors whom they love. In the current
world of quality performance and measurement, patient satisfaction
is an important metric, given the weight of patient-centeredness
since Crossing The Quality Chasm. "Engage the patient" is
one of the five tenets of UFT-A. In an interesting discussion
of patient satisfaction, and specific steps to improve scores,
Goodman and Ward have demonstrated that "Satisfied
Patients Lower Risk and Improve the Bottom Line." Besides
the very practical guidance they offer, though, their article
speaks to
the need to aggressively seek out patient complaints. This approach
to patient-centeredness offers a potential bellwether for clinical
quality problems. And the most advanced organizations are engaging
patients and families much more pro-actively—as partners
in the actual design and delivery of care—rather than asking
patients to report on their experiences after the fact. This
process, which has been labeled “Putting
the patient in the room”, is exemplified by the work
of Cincinnati Children’s (family
are considered essential members of the ‘rounding team,’)
Dana Farber (patients and family members are prominent members
of virtually every committee and task force) and perhaps most
aggressively at PeaceHealth St. Joseph’s, Bellingham WA
(where a patient is a full member of the Medical Executive Committee!)
When we launched this website almost five years ago, we proposed a range of activities for
which evidence-based
medicine, clinical practice guidelines and standardized care
could be brought to bear in far broader ways than simply with
regard to a payment model. While PROMETHEUS
Payment®, Inc., will now be given
an opportunity to demonstrate its potential with the award of
a more than $6,000,000
grant from the Robert Wood Johnson Foundation to test the model
in four pilot sites, other attempts at payment reform are surfacing.
The Geisinger Health System has launched its ProvenCare
methodology which is not really a payment
system but a warranty for the quality of the care they produce.
Limited initially to CABG surgery, tested in their own health
plan, for
a single case rate
payment the hospital and physicians agree to provide care for
all complications. Obviously this creates an incentive to prevent
those complications. In a similar vein to prevent errors, increasingly
health plans are refusing to pay for, and in Massachusetts, Pennsylvania,
Minnesota and Vermont, hospitals are agreeing not to seek payment
for “never
events.” While these new disincentives
may improve patient safety, none qualifies as actual payment
reform.
On a different note, the Blue Cross Blue Shield
plan in Massachusetts has launched a program which appears to
be a new
form of capitation with a quality bonus added
on top. The press reports they are using to launch their voluntary
program
tout the fact that the capitation rate will be severity adjusted
on an unspecified basis. They expect a very slow roll out and
acknowledge that most of the takers will be primary care physicians
who might appreciate a 10% bonus on their capitation rates. This
is pay-for-performance on a capitation platform and not true
payment reform. In fact, besides the PROMETHEUS Payment®,
model, there are essentially no other true provider payments
reform
models being proposed. Presumably the complexity in designing
something comprehensive is daunting. In her article “Physician
Compensation: Behind the Green Door,”Alice reviews
the current major payment reform proposals, including the advanced
medical home and some other ideas for primary care, and elucidates
their limitations. Only the PROMETHEUS Payment®, Inc.,
model conforms with the fundamental UFT-A principle of defining
the
payment amount from a clinical evidence-informed base making
it clinically relevant by removing actuarial risk from payment,
but also aims at engaging patients through transparency and fixing
provider accountability at the locus of control.
The battles over physician
views of quality rankings
based on efficiency
continues. In a measured analytical piece on “Comparing
Physicians on Efficiency” Arnold Milstein, M.D.
and Tom Lee, M.D., parse out nicely the differing perspectives
of customers – both patients
and subscribers, as well as employers and insurers – versus
the views of physicians regarding efficiency measurement. To
the extent that efficiency is “who is cheapest,” neither
customers, nor physicians can take comfort in the quality of
the care that is fostered in such an environment. Challenges
to the way health plans manage these programs will continue among
stakeholders until common values can be brought to bear in this
arena. Milstein and Lee rightfully challenge physicians to step
up and embrace the need for such measuring tools in the struggle
for improved quality of care in a context of limited, that is,
not infinite, resources.
From our first exposition of the principles of
UFT-A, one of the simple values at the core has always been physician
engagement, not just through medical staff structures. We have
emphasized a far more expansive view of the potential contributions
of physicians in implementation of corollary, quality-supportive
initiatives. “Guiding
Force” tells the story of the successful design and
implementation of an electronic medical record and computerized
physician order
entry system at a hospital in California where the entire project
was turned over to the physicians to make it happen. This was
not a closed medical staff, but a medical staff of volunteer
community-based physicians in a fiercely competitive market.
The article speaks very directly to the real potential in and
the positive impacts from broader physician engagement with hospitals
than simply around the implementation of clinical practice guidelines.
It also supports the proposition that with the proper attention
to governance in the development of such initiatives along with
clear principles of engagement, truly effective programs can
be crafted.
As the spotlight is focusing
more intensely on hospital quality performance, the roles of
trustees are increasingly
under government scrutiny. In addition to our suggestions regarding
how trustees can more effectively facilitate improved
physician engagement around
quality, the new publication jointly authored by the American
Health Lawyers Association
and the OIG “Corporate
Responsibility and Healthcare Quality: A Resource for Healthcare
Boards of Directors” reinforces
the intense interest of the government’s enforcers
on the critical accountability of hospital boards for effective
quality initiatives and sound quality performance. This unique
monograph elucidates the Board’s fiduciary duty for quality
and its accountability for the implementation of quality initiatives,
but, most significantly, it also presents an explicit exposition
of the government’s role in enforcing healthcare quality.
The monograph suggests ten critical questions all boards should
be asking to be sure that they are effectively fulfilling their
obligations.
The ability to get proper on call coverage for
the hospital emergency department is a growing challenge for
community hospitals as documented by the Center
for Health System Change. Specialist
physicians have become increasingly fearful of serving on the
on-call rotation given increased liability and larger numbers
of indigent and uninsured patients. Medical staffs around the
country have reduced the requirements for physicians on the medical
staff to perform this function, which long was seen as the physician’s
professional responsibility, which in earlier times they fulfilled
without much complaint. To cope with this problem, hospitals
have developed a range of strategies which the Center identifies
in their report. Now, for the first time, the OIG has issued
an advisory
opinion
explicitly approving an on-call and indigent coverage program
to pay members of the medical staff for performing these services.
Some have declaimed the safeguards this hospital established
as unwieldy and impractical, but the good news is that the OIG
has acknowledged this critical dilemma. They are still confused,
in some ways, though, over the role of the medical staff in that
most bylaws no longer require most categories of the staff to
provide coverage. And, the EMTALA liabilities to make sure coverage
is available are the hospital’s and not the medical staff
members’ unless they are on the on call schedule. This
is one of many ways in which hospitals can pay physicians to
do work on their behalf to the ultimate benefit of their patients.
Clinical integration is a technique by which independent
physicians and group practices can relate to one another for
quality and still bargain collectively over price with managed
care plans. Although cited by the FTC in virtually every settlement
with IPAs and combinations that bargained collusively over fees,
the indicia of proper clinical integration have not been well
defined. Some settlements and one Advisory
Opinion,
now almost six years old, have staked out some of the tur;, but
most of what the behavior the government has reviewed, it has
always seemed, were motivated more by price aspirations than
quality improvement. The lack of clear guidance has led the American
Hospital Association to call
on the FTC and DOJ for
greater specificity
in describing what would qualify as good
clinical integration.
Now, in their advisory opinion to the Greater
Rochester IPA,
the
FTC has described a program which seems far more to emanate from
a quality impetus. Because GRIPA was well integrated clinically
for the work it did in connection with HMO products, it had a
relatively easier time orienting its activities to the PPO, fee
for service, business where the antitrust risks are far greater.
The opinion is a useful statement of one modern model of clinical
integration.
The recent change in the JCAHO
Medical Staff Standard 1.20
to require that the medical staff bylaws be an integrated document
has created a firestorm of controversy that should be less than
a tempest in a teapot. Prediction of expensive disasters in redrafting
bylaws, and arguing over what is process versus what is procedure,
is absurd and fomented by a cadre of law firms who have made
significant income from advising medical staffs and hospitals
that the bylaws should be divided up into five different sections
so that they may be more easily amended. The Medical Staff Bylaws
are the Constitution of the Medical Staff and should be amended
about as easily as the US Constitution is amended. Alice has
written and advised on medical staff bylaws for more than 100
medical staffs all around the country over the last 30 years,
and this is not all she does, as it is for some law firms. She
has never advised a medical staff to disaggregate their bylaws.
The other noteworthy change adopted by the JCAHO for 2009 is
that the medical staff should have the right to propose medical
staff bylaws changes directly to the board. This should be non-threatening
unless you have a renegade medical staff or a renegade medical
executive committee where the representative function of the
MEC has broken down. It would be the board’s responsibility
to sort this out if the medical staff asked for changes, not
recommended by the MEC, that were not in the best interests of
the hospital. Everyone should calm down about these feared power
struggles and focus on the real purpose of the medical staff,
which is to be responsible for quality in the institution. When
organizations do that effectively the medical staff can become
more galvanized for a far better purpose than internal turf and
power struggles.
For years, we have been working on techniques to
help physicians and hospitals collaborate more effectively to
improve quality. In our white paper for IHI
and the two
day programs we do for IHI which routinely sell out weeks
in advance
as well as other
offerings,
we describe a six step plan to accomplish improved engagement
around quality. Now, in “Sharing
the Quality Agenda with Physicians”,
we focus explicitly on the unique responsibility of lay
trustees to create
more effective physician engagement with hospitals. We explain how the board can ask the right questions
and seek the right data to make engagement and quality strides
effective and real. We emphasize the importance of meeting the
varying needs of different segments of the medical staff and
describe Stark compliant initiatives that should be considered.
Pay for performance programs
show no signs of abating in popularity, yet their impact remains
equivocal. Whether quality
would be better if physicians within groups also paid themselves
based on quality performance is unknown. If the incentives of
P4P are to have impact, how are those monies distributed to the
individual physicians once the group gets paid? There is virtually
nothing in the literature on point. In “Physician
Compensation for Quality: Behind The Group’s Green Door,” Alice
looks at the data on P4P programs, the basics of traditional
compensation within groups and then presents the findings from
a unique survey which was sent out on her behalf by the AMGA
producing responses from 14 groups around the country who are
variably paying for quality as part of physician compensation.
Some report significant improvement in quality performance, too.
Alice then looks at the payment reform models on the horizon
and concludes that traditional notions of productivity, on which
most current group compensation models turn, will not reward
what the new systems, and most particularly the PROMETHEUS Payment® model
(www.prometheuspayment.org) is designed to generate. She examines
whether the Stark rules on compensation will be a barrier
to changed, creative approaches, concludes that it will not,
and then looks at what employment contracts will have to accommodate
to make physician compensation for quality within groups real
and of value to both patients and physicians.
On December 5, 2006, Health Affairs published a
web
exclusive series of articles offering some fascinating
perspectives on hospital-physician relationships which
are particularly relevant to physician engagement
with hospitals around quality. Berenson, Ginsburg and May
observe that physicians have increasingly become competitors
of the
hospitals which were formerly their most valued "significant others".
Fisher, et al. argue that hospital quality results should be
measured to include the "extended hospital medical
staff" which
would take in physicians who refer to the facility but never
set foot in it. Wilensky, Wolter, and Fischer present a new spin
on gainsharing as a way to meet the ever elusive goal of "aligned
incentives". Smithson and Baker contend that the medical
staff organization itself is a moribund anomaly and not
worth accommodating at all. Goldsmith offers a view of
the medical
staff as a Darwinian coral reef with predators and prey;
while Cortese and Smoldt claim that legally integrated
hospital-physician entities are the only hope for the future.
The provocative juxtaposition of these articles reflects the
intensity of interest in the intersection of physicians’ economic
behavior with the hospital’s status as an institution where
most of the activities are driven by physician orders. All acknowledge
that improved medical staff-hospital relationships are indispensable
in today’s world.
We make no argument for a one-solution-fits-all
approach. We have seen circumstances in which employed physicians
are just
as restive and disengaged as independent physicians and, by contrast
hospitals where the independent medical staff has taken significant
responsibility for enhancing quality of services rendered within
institutions’ four walls. In our programs
for IHI,
the IHI
white paper, and other work with clients, we take
the position that most physicians have a profound interest in
quality, particularly in terms of outcomes for their patients
and efficiency in the use of their time. The holy grail of “aligned
incentives” and structure-driven solutions can only offer
short-lived hope unless these efforts recognize that physicians
themselves are increasingly reported on for their quality results,
risk fraud and abuse enforcement for quality failures, and have
a strong cultural concern for excellence and professionalism.
All combine to define their business case for quality which must
be the fulcrum to better relationships with hospitals if they
are to be sustainable.
Among the many strategies for closer alignment
between hospitals and their physicians are the proliferating
joint ventures and financially driven exercises, including gainsharing,
that are intended to capture with more revenues the loyalty of
the medical staff members who are involved. In her editorial
in a recent issue of the Journal of Oncology, "Physician-Hospital
Partnerships: What Really Counts?",
Alice argues that unless the quality implications of hospital-physician
ventures
are their driving purpose, these transactions may generate short-term
revenues, but they will not feed the core needs of their participants.
Still, they may have an important role within the context of
a well-thought out physician engagement strategy.
What qualifies as excellent care is the core of
any quality discussion. When the issue is who are “the
very best doctors”, there are new questions worth asking.
Jim has raised these in an incisive PowerPoint
presentation
which
supported a program he conducted for a large physician group.
He articulates commonly cited attributes of good doctors – reputation,
technical skill, pedigree and bedside manner--- and distinguishes
them from uncommonly cited attributes of good doctors such as
reliability and accessibility. What physicians have traditionally
valued in their assessment of what makes the best physicians
is more and more at variance with views of high quality expressed
by regulators and payers, and is rarely based on data. How to
marry both views and improve quality of care is a persistent
challenge which we believe can be met through the kind of organized
analysis which we present in our framework for physician engagement
in the IHI
white paper.
The increasing emphasis on quality as a basis for
fraud and abuse enforcement is now clear. Yet many compliance
officers are not integrated into the quality activities of the
organizations they serve. In her viewpoint on “Doing
What Really Matters: The Compliance Connection to Healthcare
Quality” in the Journal of Health Care Compliance, Alice presents three
activities through which compliance officers can work more effectively
on quality issues in addition to the fundamental challenge of
raising the consciousness of the board and administration of
any healthcare entity to these new quality mandates.
UFT-A principles call for using clinical practice
guidelines at the center of a wide array of administrative and
clinical processes, and most particularly with respect to payment.
A fascinating report on one organization’s response to
a managed care plan’s creation of a high performance network
(a far narrower network for more efficient providers) can be
found in the story of how the Virginia-Mason
Medical Center (VM) redesigned care delivery to achieve better
payment
. Aetna had been planning to exclude VM from its Aexcel program,
but four major employers agreed to reconsider including VM if
they would work toward specific cost reductions. The report of
the steps that were taken is especially interesting coming from
a health care system that was revamping many of its clinical
processes to achieve stellar results. VM is widely regarded as
a principal avatar for implementing the Toyota production model
in American health care. This story is particularly intriguing
since Aetna represented only 10% of the Seattle market.
The innovations relied significantly on the use of guidelines-based
care. For the relatively limited services on which they focused
--- pharmaceuticals, emergency department visits, diagnostic
testing, some physician services in treatment of migraines, use
of magnetic resonance imaging, and treatment of GERD – there
were some limits to the exercise. There was no formal program
evaluation and therefore no comprehensive data corresponding
to the major cost centers that had been initially identified
as meriting change. The impact of VM’s interventions was
difficult to assess because relative data remained proprietary.
The impact on VM’s margins was also entirely unclear.
Despite these limitations, the elements of success
in the program reflect many of the UFT-A principles and some
that mirror PROMETHEUS
Payment® principles. The collaboration among purchasers, health
plan and provider was critical, as was access to detailed cost
data. This issue raises, yet again, a fundamental problem – namely,
even very sophisticated and highly integrated provider networks
have virtually no data available with respect to what it costs
them to treat a patient for a condition. Providers ought to begin
to develop this data whether PROMETHEUS Payment® comes
to their local movie theater soon or not.
Improved clinical collaboration,
which is at the core of the PROMETHEUS Payment® program, also
is relevant to
the five UFT-A principles – (1) standardize; (2) simplify;
(3) make clinically relevant; (4) engage the patients; and (5)
fix accountability at the locus of control. These principles,
combined with highest and best use of all clinicians, administrative
burden reduction and reinvigorated time and touch with patients,
will be keys to PROMETHEUS Payment® success too. In fact, much
of what the new payment model rewards, providers should be doing
anyway, whether anyone pays them differently or not. Quality
driven efficiencies – not in the “who is cheapest” sense,
but in the “how can we be more resourceful and use our
time and resources better” sense --- ought to compel providers
today. UFT-A calls for the methodical elimination of self-imposedinefficiences
which steal time and touch from care. In her editorial "A
New Payment Model for Quality: Why Care Now?" Alice
articulates some of the tenets of PROMETHEUS Payment® that all
providers should be working to make real without a new payment
model.
Clinical practice guidelines (CPGs) are the foundation
for UFT-A principles and also the predicate for PROMETHEUS Payment® Evidence-informed
Case Rates®? (ECRs®). In their article “Integrating
Clinical Practice Guidelines Into The Routine of Everyday Practice”,
cardiologists John Brush, Martha Radford and Harlan Krumholz
confront the complexity of many CPGs – and particularly
the spectacularly well documented ones of the American College
of Cardiology/American Heart Association – and how that
impedes their implementation on a day to day basis by practicing
physicians. Published in 2005, their propositions have not been
widely discussed, but the issues presented will have to be addressed
if CPGs are to be used more widely than they have been. The application
of the ‘heuristics’ they cite as endemic in the practice
of medicine --- unwritten rules of thumb, practical short-cuts,
and other work-arounds – must be explicitly acknowledged
and taken into account to get to more standardized and evidence-based
care. Fortunately they offer specific solutions for professional
organizations creating CPGs and physicians who would seek to
apply them. All will lead toward more reliable standardization
to the science.
The creation of ‘high
performance networks,’ which
tier and exclude some providers with the stated purpose of incentivizing
patients to go to the ‘better’ physicians has met
with considerable alarm from physicians.
Decried as purely networks of the cheapest, the debates today
include direct challenges
to the quality of the data used to exclude some in favor of the
preferred status of others. The tensions are only escalating.
In “Doctors
Rated But Can’t Get Second Opinion”
the Washington Post reports on tiering programs with report cards
in Massachusetts, the District of Columbia, Seattle, New Jersey,
New York and Connecticut which have met enormous resistance,
including a threat by the New York Attorney General to enjoin
United Healthcare’s implementation there of the program
it launched in St. Louis. Lawsuits abound and the struggles over
the intersection of cost and quality continue.
With the announcement of an initiative to launch
September 2007, CMS will seek information from 500 hospitals
nationwide about physician investment in them. Of broader significance,
however, they will also be asking hospitals for disclosure of
hospital-physician compensation relationships under Stark. Half
of the hospitals are those who did not respond to a voluntary
request for data. The others will be chosen at random. In the
announcement of the now mandatory
reporting,
the government makes it clear that the information can be used
by them for any legitimate purposes including enforcement. While
this announcement is a good reason for hospitals and physicians
throughout the country to review all such relationships for compliance,
it is not well understood that the Stark regulations offer both
flexibility and some opportunities for hospitals to pay physicians
directly for work they do for the hospital’s benefit. The
Phase II regulations made it clear that compensation for physician
personal services provided to the hospital has safe harbors which
are specified in the definition of ‘fair market value’.
At the same time the preface to the regulations explicitly states
that paying outside of the 50th percentile of MGMA does not necessarily
violate the law, although safety is not guaranteed there.
Paying physicians for their time in helping the
institution improve its quality performance is increasingly important
as
physicians struggle against lowering reimbursement and higher
overhead expenses. As the activities for which hospitals pay
physicians expand, the fundamental problem is that they can be
paid primarily for their time --- the one dear commodity they
have little to spare. There are, however, a host of things hospitals
can provide which benefit physicians and enhance their business
case, while improving quality --- all without making cash payments
to them. These are issues we have addressed in our articles in
Hospitals and Health Networks Online (Part1, Part
2), the
Journal of Oncology Practice,
the IHI
White paper and more.
Some of
our clients are also looking more closely at rewarding the “good
citizenship” of their active medical staff members ---
the ones who attend meetings, and work on quality initiatives
and help the organization meet quality targets. Without paying
for achievement of good results (which patients expect of their
hospitals and physicians anyway), some hospitals are considering
more innovative approaches: when departments are working hard
and achieving good quality scores, they get departmental perquisities
from flat screen TVs, to free internet access in the departmental
doctors’ lounge, to a preferred line for transcription
or lab results, to concierge-type support for their offices in
the admission process. None of these implicate the Stark statute
because they are not about providing physicians with a financial
benefit or service they would otherwise pay for themselves. These
are services specifically valuable to the hospital, but they
give the physicians back time. Using the compliance education
regulatory exception under Stark has become even more popular
as the legal issues associated with quality, including antitrust
and P4P, have multiplied.
David Eddy has long been regarded as one of the
most prominent and elegant thinkers regarding evidence-based
medicine. His 1998 article on performance measurement in Health
Affairs presaged many of the issues, including attribution,
now being decried in the context of pay for performance. In 2005
he wrote about the confounding by most users of the term ‘evidence-based
medicine’ to apply to both the evaluation of the quality
of the science supporting clinical processes as well as a separate
and distinct concept of the application of that valuation to
other societal choices related to payment
and benefit coverage. Now, in a provocative dialogue with
Sean Tunis, who formerly managed technology coverage policy for
CMS, David elucidates further the boundaries of true
'evidence-based' medicine,
and its applications. Without cost and value judgments introduced
in the application of the evidence to the policies for which
it will be used (e.g., coverage and payment policy), though,
he argues that the application of the first part of the analysis
(what is the quality of the evidence on which clinical activities
should unfold) is not enough. “What people need to realize
is that by pretending to ignore costs, we are not only wasting
money, we are also spoiling quality. If one cannot consider costs,
then there is no way to address efficiency or set priorities.” “…[A]fter
you have analyzed the evidence for a performance measure, you
still have to make a value judgment about whether the benefits
of increasing performance outweigh any harms and justify any
costs.”
UFT-A principles would say that if you start with
CPGs based on the best evidence available, which often includes
reasoned
consensus, and evaluate the resource costs associated with providing
that continuum of care for a condition, there is a better chance
that much of equivocal value would be excluded. The PROMETHEUS
Payment® program is beginning with Evidence-informed Case
Rates™ calculated from claims data, which everyone recognizes
is not
ideal. Starting with calculating payments made in large, national
claims databases for core services required by guidelines, adding
dollars for discretionary services recommended by guidelines
but not for all patients, augmenting that with an explicit additional
financial margin for providers, plus a “warranty” corridor
for expected appropriate clinical variation, combined with risk
adjustment, the Design Team believe the major drawbacks to using
claims data to construct rates has been confronted. We think
this represents a far better accounting for the kinds of decisions
David calls for than what has existed in any other payment models
of which we are aware.The longer range view of PROMETHEUS Payment®,
would expect providers to be developing far more explicit evidence
of what it costs them to treat their patients in accordance with
science.
The interest of federal prosecutors
in quality has never been as intense as it is today. As a
dramatic manifestation
of prosecutorial focus on board responsibility for hospital
quality generally and “the quality we are paying for,” attached
is a PowerPoint
presentation created by James G. Sheehan, Associate
Attorney in the U.S. Attorney’s Office of Philadelphia.
He is particularly interested in how boards remain indifferent
to quality while cheerfully accepting the financial rewards
of less than optimal care. You will note that, as in
many prior instances, he is identifying both specific
cases
that will
be
models for future prosecutions as well as upcoming new
approaches to prosecution. He has always followed through
on such public
statements. All hospitals should take heed.
For those not familiar with the role of the Office
of the Inspector General as distinct from the Department of Justice,
recent testimony
by Daniel Levinson, on the occasion of the 30th anniversary of
the OIG, the 20th anniversary of the False Claims Act, and the
10th anniversary of HIPAA, provides a focused look at the breadth
of their activities.
With the crisis regarding
the Sustainable Growth Rate (SGR) creating a significant reduction
in physician reimbursement
under Medicare for 2007, Congress enacted the Tax Relief and
Healthcare Act of 2006. While Congress froze payment rates to
2006 levels, they also created a program to provide bonuses for
physicians to report on consensus based quality measures. The
first measures would be those used in the Physician
Voluntary Reporting Program until the end
of 2007. After that the measures will be specialty focused and
consensus based, meaning endorsed by a national organization
such as the Ambulatory Quality Alliance or the National Quality
Forum. The standards apply to physicians, non-physician practitioners,
and physical and occupational therapists. The bonus of 1.5% of
allowed charges for satisfactory professional service reporting
will give physicians more of a reason to pay attention to what
their specialty acknowledges as legitimate measures of quality
but the total payment is capped. New data specifications make
it clear there will be added administrative burden to get the
payments. There are no appeals of the determinations that the
Secretary makes on this payment and there will be sampling to
validate the reporting. The system need not be implemented by
regulation but may be implemented through program memoranda.
These are easily accessed through the CMS
website (when it is
working).
When Congress appropriates $1.35 billion dollars
for physician quality improvement initiatives, the federal government
is getting serious about quality. Section
204 of the Medicare
Improvements and Expansion Act of 2006
created a demonstration project to evaluate the viability of
the “medical
home”
concept sponsored by the American College of Physicians and the
American Academy of Family Physicians for primary care physicians
to coordinate care on quality
issues.
At the same time, under Section 203, the OIG was called on to
report in two years on “never events” (e.g. amputating
the wrong leg, operating on the wrong patient) which the National
Quality Forum
has identified as errors that should never happen. The issue
for the government is how to avoid paying for these events and
to what extent payment is denied. For example, if the wrong leg
is amputated, should only the hospital not be paid or also the
anesthesiologist and the surgeon who participated? These questions
have no answers yet, but the Congressional focus on these issues
brings Medicare far more in line with the direction private industry
has been moving, and rather faster than has typically been the
case.
Implementation of the PROMETHEUS Payment® model
is progressing. With sponsorship from the Commonwealth Fund to
model Evidence-informed Case Rates™, the program expects
to launch in the latter part of 2007. To make it real, there
are contractual issues that must be addressed including what
is appealable and what is not. In her 2007 Health Law Handbook
chapter Alice provides “The
PROMETHEUS Payment® Program:
A Legal Blueprint” which outlines not only contractual terms but also potential
liability and data issues associated with PROMETHEUS Payment® implementation.
Quality is increasingly becoming part of the basis
on which providers compete. While advertising about quality really
began with managed care organizations, it has now spread to many
hospitals and increasingly will b
