Medical Staff

Measuring Performance for Effective Health Care Change

Medical Staff Affairs Monthly, November 21, 2005

Dear Colleague,

Researchers at Rockefeller University have apparently determined that the "sniff test" is a universal methodology for determining what's good from what's gone rotten. In their studies published in Nature magazine, these scientists have found that the nematode worm, C. elegans, will avoid odors produced by pathogenic bacteria that can infect its intestinal tract. Indeed, after exposure to pathogenic bacteria, the worms alter their olfactory preferences, learning to avoid bad bacteria and becoming attracted instead to harmless bacteria.

For human's the sniff test is a long standing public health practice-if the food smells bad, don't eat it! So in today's column, let's try applying it to some of news in the health care community.

As many of you are aware, the nation's foremost accreditor of hospitals has been in the news for quietly selling to third parties, mostly insurers, hospital performance data which it collects from members. Smell bad? Apparently the JCAHO executive committee and Board agree and will discontinue a data mining contract between a JCAHO subsidiary and the national Blue Cross Blue Shield Association. Paranoia concerning the misuse of performance data is rampant in the provider community and there is no excuse for JCAHO to fan these flames of discontent in order to squeeze out a few dollars in the marketplace.

On November 14, CMS announced that hospitals participating in the Premier Hospital Quality Incentive demonstration, a Medicare pay-for-performance demonstration, showed measurable improvements. This is Medicare's first pay for performance (P4P) demonstration and it provides the first statistical evidence that this model improves the quality of care. Hospitals in the first year of the demonstration in the top 10% for a given condition were awarded a 2% bonus on their Medicare payments for that condition and hospitals in the second 10% were given a 1% bonus. Bonuses totaled $8.85 million, CMS said. (see CMS press release at http://www.cms.hhs.gov/media/press/release.asp?Counter=1729).

Consistent with the success in this experiment, CMS announced a new voluntary program for physicians to report evidence-based, consensus quality measures. In the first phase of the program which is to begin in January, Medicare will allow doctors to submit data on 36 quality measures which have been developed in conjunction with a large number of physician organizations and other experts, including the National Quality Forum. The doctor's will get feedback on their performance but initially the program will not lead to changes in Medicare reimbursement.

The pay-for-performance element could be added in once the reporting system is vetted. The physicians participating might also use the performance data to negotiate higher payments with private insurers, many of whom now employ P4P reimbursement mechanisms. Does this "smell" appropriate to you? Not to the American Medical Association whose House of Delegates voted at its semi-annual policymaking meeting to oppose the Physician Voluntary Reporting Program (PVRP).

Apparently the delegates were concerned that no pay was attached to the initial project, a circumstance which particularly rankled members because of the announced 4.4% cut in the Medicare physician fee schedule announced for the coming year. The second rationale for opposition is "errors in both the methodology and substance of the program." To those of us working with medical staff performance improvement initiatives this latter argument will sound familiar. When will the data underlying performance improvement work ever satisfy the rigorous expectations of all parties? Nothing is going to stop the P4P movement from going forward in this country as our health care expenditures continue to spiral out of control.

Rather than opposition, our medical organizations need to continuously critique these approaches and steer them toward efficacy. In an informative conference held earlier this year, The Commonwealth Fund noted that specialty physicians and their specialty organizations have been notably absent in driving the creation of quality measures which will guide future performance improvement initiatives. Several articles on their Web site share the history of these organizations in the quality measurement movement and catalog their current involvement and positions. (http://www.cmwf.org/publications/publications_show.htm?doc_id=318260). Like the nematode C. elegans, we need to alter our collective olfactory bulbs so that we are attracted to aggressive initiatives which measure performance and use the resulting data to implement effective health care change.

Federal lawmakers are sniffing the air and are leery of P4P programs for another reason. In a hearing on reforming Medicare physician payments by the House Energy and Commerce Committee's health subcommittee, Rep. Lois Capps (D-Calif) warned, "We must be absolutely sure we are not creating incentives for doctors to deny care".

Maybe such thoughts were sparked by a CMS announcement on November 10th that it had saved the government 9.5 billion dollars in the past year by reducing improper fee for service Medicare claims from 10.1% to 5.2%. Or maybe the air was just fouled by the notice that four physicians connected to Redding Hospital in California have agreed to a $32.5 million settlement in connection with claims they performed unnecessary cardiac surgeries (Click here to see a statement by the attorney gereral). Do you know what is happening in your cardiac suite?

The OIG 2006 work plan has announced that one area of focus will be on the use of cardiac stents, which it deems as an area ripe for abuse. Tenet, the previous owner of Redding Hospital which it sold in July 2004 after discovery of massive fraud in the hospital cardiac program, has established a settlement fund of $395 million for the more than 750 plaintiffs seeking redress for alleged unnecessary procedures performed at the hospital.

All of us who hope to play a role in improving health care in this nation need to maintain an acute sense of smell for what's right and what's wrong. But once our noses alert us to a concern, only careful study and open minds will help us sort out the myriad complexities of our dysfunctional health system. Fortunately, right now, the smells wafting across the nation are largely those of turkey, sweet potatoes, and Thanksgiving banquets. And I know my olfactory senses find that attractive. Enjoy your holiday!

Best regards,

Todd Sagin, MD, JD
National Medical Director
The Greeley Company

Related Resources of Interest:

Early Experience with Pay-for-Performance: From Concept to Practice, Meredith B. Rosenthal, Ph.D., Richard G. Frank, Ph.D., Zhonghe Li, M.A. et al., Journal of the American Medical Association, October 12, 2005, 294 (14): 1788-93

Stepping Up to the Plate- a initiative by the American Board of Internal Medicine on quality and accountability: http://www.abimfoundation.org/suttp/index.htm

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