Measuring Quality

  The U.S. economy is experiencing a recession, which in some ways might be worse than the Great Depression. Certainly it involves the loss of more stock market dollars than in the crash of the 1920s. The economic crisis has only served to emphasize the unsustainability of the healthcare status quo. Healthcare spending accounts for 16% of the gross domestic product and is increasing at an average annual rate of about 7%. Medicare expenditures are up from $219 billion in 2000 to a projected $486 billion in 2009. Medicare premiums, deductibles, and cost-sharing are projected to consume 28% of the average beneficiaries’ Social Security check in 2010. In fact, the Medicare Part A Trust fund is projected to be depleted by 2016. And although Americans spend more per capita on healthcare than any other industrialized country, many indicators of quality (such as preventable deaths and timely access to primary care) are below those of similar nations. We have serious problems with safety, quality, and waste. We are also facing real work force issues across the healthcare system at the patient level. These multiple factors are compounding the challenge of delivering complete, safe and cost controlled care.   Although quality measurement and improvement may seem to be recent concepts in American healthcare, these ideas actually date back to the early 1900’s with the work of Ernest Codman, MD. He tracked every patient to determine the effectiveness of their treatment and developed the Minimum Standard for Hospitals to help eliminate substandard care. As Kristine Martin Anderson and Kathryn Schulke discussed in their article, “Linking Public Accountablity to Quality Improvement¹,” prior to 1966, improvements in healthcare quality focused primarily on structure (eg evaluating staffing levels, licensing and accreditation). It was Avedis Donabedian who believed quality management should also include evaluation of processes and outcomes, developing standards of care and clinical guidelines, which form the basis for today’s quality measures.   However, large scale public reporting of quality is a relatively new concept. The Health Care Financing Administration (HCFA, since renamed the Centers for Medicare & Medicaid Services) first attempted to measure and publicly report hospital outcomes from 1986 to 1993, but it withdrew its mortality measures because of widespread criticism. CMS reintroduced “outcomes reporting” in 2006 with risk-adjusted mortality rates for heart failure and heart attack. HCFA developed a set of ‘quality indicators’ (opting not to use the term ‘measures’) acknowledging that the available data focused on care processes and could not capture or describe most of the factors influencing patient outcomes. In 1999, the Joint Commission on Accreditation of Healthcare Organizations (now simply the Joint Commission) began to develop a set of core measures for hospitals. The core measures were formally adopted by act of Congress in 2003 as the basis for a reimbursement incentive for voluntary performance reporting.

Report on What and by Whom? The NQF

  Even the brief summary above demonstrates the difficulties experienced in defining and measuring quality in healthcare. How can this huge issue be tackled? Enter The National Quality Forum (NQF). The NQF is a not-for-profit membership organization created to develop and implement a national strategy for healthcare quality measurement and reporting. The mission of the National Quality Forum is to improve the quality of American healthcare by setting national priorities and goals for performance improvement, endorsing national consensus standards for measuring and publicly reporting on performance, and promoting the attainment of national goals through education and outreach programs. It is likely that NQF-endorsed standards will be the primary standards used to measure and report on the quality and efficiency of healthcare in the U.S. The NQF has hundreds of members (physician specialty groups, nursing organizations, insurance companies, hospitals, healthcare agencies, etc.). Recently, the Association for the Advancement of Wound Care (AAWC) became the first member specifically focused on the topic of wound care. However, other specialty groups like the American Society of Plastic Surgeons and the American Physical Therapy Association have participated in projects that focused on wound care.   Nevertheless, from a more global healthcare perspective, even if we knew what it was we were going to follow to measure ‘quality,’ how can clinicians or hospitals be incentivized either to do a better job of delivering care, or to report their progress?

Pay for Performance

  Given the impending bankruptcy of the Medicare system, a change to the payment system is urgently needed. A major criticism has been that the payment system is neutral or negative with respect to quality. For example, a hospital is paid more when a patient is readmitted to the hospital with an infection he acquired there. Therefore, the Center for Medicare Services (CMS) initiated an incentive plan to improve quality known as ‘Pay for Performance’ (P4P). In this context, CMS defines ‘performance’ as, ‘the right care, to the right patient, at the right time.’ It is not, as the name might imply, payment only if the patient does well. In this case, payment is linked to whether the clinician performs certain tasks in a given time frame to specific patients. For example, are patients who smoke counseled to stop smoking? The payment is linked to whether the counseling is delivered, not to whether the patient actually stops smoking.   To develop and implement these initiatives, CMS is collaborating with a wide range of other public agencies and private organizations who have a common goal of improving quality and avoiding unnecessary healthcare costs, including the National Quality Forum (NQF), the Joint Commission of the Accreditation of Health Care Organizations (JCAHO), the National Committee for Quality Assurance (NCQA), the Agency for Health Care Research and Quality (AHRQ), and the American Medical Association (AMA). CMS is also providing technical assistance to a wide range of health care providers through its Quality Improvement Organizations (QIOs).

Physician Reporting and Money on the Table: PQRI

  On December 20, 2006 the President signed the Tax Relief and Health Care Act of 2006 (TRHCA), which authorized CMS to establish and implement a physician quality reporting system. In response to the mandate, CMS created the Physician Quality Reporting Initiative (PQRI).² The Physician Quality Reporting Initiative is a voluntary physician quality reporting system. The Medicare Improvements for Patients and Providers Act (MIPAA) of 2008 authorized a 2% bonus for those who successfully report quality measures. The 2009 PQRI contains 153 measures applicable to primary and specialty physicians. To be eligible for the bonus, measures must be reported in at least 80% of encounters where a measure applies. The incentive is awarded for reporting on applicable measures, regardless of whether or not the measure was met. (In other words, at this stage of the program, providers can get the bonus just for gathering information.) In response to the difficulties faced with the 2007 PQRI Program, in April 2008 CMS expanded the data collection process from the complex claims based reporting process to include reporting data via Qualified Patient registries. Thousands of organizations showed interest, but only 32 made it through CMS’ complex vetting process. The program has not gone entirely smooth. The Medical Group Management Association (MGMA) released a report showing that of responding PQRI participants, about 63% had moderate to extreme difficulty capturing and submitting data, nearly 70% reported little or no guidance in improving patient outcomes, and almost 93% had trouble obtaining their 2007 feedback reports.³ Therefore, it is safe to say that the process of participating in PQRI continues to be a work in progress.   Remember that initially, the goal of PQRI is to get basic information from a broad cross-section of clinicians on very basic interventions, so these measures are not specific to wound care. Nevertheless, any physician practicing wound care can still enjoy the bonus money available by submitting data they collect in their general care of patients. However, exactly how does this process work?   In this example, the author would like to give full disclosure. I am the Medical Director of the Intellicure Research Consortium (‘IRC’), and the IRC is one of the 32 CMS Qualified Patient Registries for the 2008 PQRI Program. As a result, I have some information on the “process side” of this equation.   Note: I use this only as an example of what any physician could submit because clinicians can work with other registries to do the same thing. Intellicure selected 12 measures, which were readily available in the electronic medical records of patients seen in hospital based, outpatient wound centers, even though most of these measures are not directly related to wound care. Physicians only need to provide data on three measures. (As a registry, Intellicure assesses 12 measures to make sure that it can provide data on at least three measures for each clinician):     1. High Blood pressure Control in Type 1 or 2 Diabetes Mellitus     2. Screening for Future Fall Risk     3. Advance Care Plan     4. Influenza Vaccination for Patients ≥ 50 Years Old     5. Pneumonia Vaccination for Patients 65 years and Older     6. Inquiry Regarding Tobacco Use     7. Advising Smokers to Quit     8. Diabetic Foot and Ankle Care, Peripheral Neuropathy: Neurological Evaluation     9. Universal Weight Screening and Follow-Up     10. Universal Influenza Vaccine Screening and Counseling     11. Universal Documentation and Verification of Current Medications in the Medical Record     12. Pain Assessment Prior to Initiation of Patient Treatment

How Exactly Does Data Get Submitted?

  A physician group or electronic registry must first define the measures it intends to collect and submit to CMS. The registry creates a validation plan that ascertains what participating members are eligible professionals under the 2008 PQRI program and whether they have accurate data on at least 80% of their eligible patients, visits, procedures, or episodes for a given measure. The registry screens for inappropriate data entries coupled with random sampling of for accuracy, completeness, and adherence to required sampling methods. The registry must be a HIPAA partner and be able to ensure physical security of records. Many technical specifications must be met for the actual data transmission to CMS with regard to security and interoperability, which are beyond the scope of this article, An XML file is created for each provider in the Qualified Patient Registry using the providers National Provider Identification (‘NPI’) number and their Taxpayer Identification Number (‘TIN’) pair to uniquely identify each submission. These files identify the three measures selected by the clinician, the reporting rate, and the performance rate for each measure. Those XML files are then encrypted and uploaded to a secure location on the CMS intranet where they are parsed by CMS and the data is inserted into the larger PQRI dataset just as if they had been uploaded through the claims process. Providers who successfully submit their data should expect to receive a bonus check for 1.5% of all successfully billed Medicare claims. The check will be payable to the taxpayer associated with the TIN and mailed to that address.   Here is an example of one of the simplest PQRI measures, to review what has been discussed so far. Example: If one wanted to make sure that a general practitioner was doing a good job of inquiring regarding tobacco use. This measure is reported at least once per reporting period for all patients. To report information for this measure, the provider must find a way to communicate to his billing staff that they have successfully made an inquiry. This is accomplished by marking two CPT Category II codes on the Superbill so that this information will be transmitted to CMS via the patient’s insurance claim. But remember, it is not enough to inquire about a few patients’ tobacco use. The goal is to make the inquiry on 100% of patients aged 18 years or older.   In other words, there has to be a denominator of some sort. And what about services or interventions where there is not a specific procedure code? A practice would have to keep data on all the patients who need that sort of intervention, as well all the patients for whom it is provided. Continuing with the simple example of inquiring about tobacco use.   Again, to qualify for the tobacco use inquiry measure, one is looking for the percentage of patients aged 18 years or older who were queried about tobacco use one or more times within 24 months. The first part of the ratio is the numerator. It is important to identify the patients who were queried about tobacco use. This is done by reviewing the claims produced for these patients, and looking for the successful matches of CPT II 1000F, Tobacco use assessed and one more code from the set of CPT II 1034F, 1035F, or 1036F, which are current tobacco smoker, current smokeless tobacco user, and current tobacco non-user respectively. That’s correct, it’s not good enough to just say that tobacco use was assessed; the right answer has to be provided. You can also indicate that tobacco use was not assessed by using CPT II 1000F with modifier -8P. If everyone isn’t confused enough, it is time to discuss the denominator. Thankfully, it is much easier when one is only looking for all patients aged 18 years and older who had a CPT E/M service during the time frame.   With all of these rules it’s no wonder that CMS only had to pay eligible providers slightly more than $36 million in incentive payments for the 2007 PQRI reporting period. The average bonus paid to individual providers was a mere $635. Of the more than 14 million quality data codes submitted, 48% of submissions were invalid.

What’s it to you?

  The PQRI process is voluntary. However, in the next phase of Pay for Performance, many expect CMS make the program budget neutral, compensating the top 2 deciles by penalizing the lowest 2 deciles of providers based upon their performance as documented by their submissions. Eventually, physicians will not be able to afford to not participate. So, while the process seems rather complex, given that the measures are pretty straightforward, now is the time for clinicians to figure out how they will participate in the process.

Quality Measures Specific to Wound Care

  The first attempt at this involves a very low level pass at the most basic of interventions, and is largely focused on the process of how to get data into CMS to create report cards. In the future, the measures will become more sophisticated, and likely, more specific to certain specialties. Stop a wound care clinician on the street and ask them on the spot, “what is the most important intervention for a neuropathic diabetic foot ulcer?” Hopefully they will say, “Off-loading.” It seems logical that if we really want to measure quality in the wound care industry, we ought to at least measure whether diabetic foot ulcers get off-loading and venous stasis ulcers are put in adequate compression.   Wound care as a topic, was tackled by the AMA PQRI in collaboration with the American Society of Plastic Surgeons with. Dr. William Wooden, Professor of Plastic Surgery at Indiana Purdue University, along with co Chair Dr. Scott Endsley. Dr. Wooden was very generous with his time in helping prepare this article. He and Dr. Endsley created a work group with a strong multidisciplinary membership whose challenge was to support clinicians practicing wound care by creating evidence based PQRI measures. The measures had to be focused on the core wound ICD 9’s and provide an insight into the practices’ level quality of wound care. The measures were also crafted to provide an avenue of improving wound care for those practices that were not currently meeting the standards. The group felt that these “snippets” of quality care could help under performing practices develop an expanded understanding of the current literature and practice standards, thus helping to redirect care in a more positive fashion. The concept was to use measures as a method of education to drive stronger core values. Wound care represents a tremendously diverse group of patients, co-morbid states, and practitioners. Thus, wound management is a poorly circumscribed area of practice when compared to other specialties. Greater education was identified as a core need due to the diversity of providers in the wound care field. The measures recommended by the committee were:   •Measure #1: Use of superficial swab culture technique in patients with skin ulcers (overuse measure)   •Measure #2: Use of wet to dry dressings in patients with skin ulcers (overuse measure)   •Measure #3: Assessment of wound characteristics in patients undergoing debridement   •Measure #4: Use of compression system in patients with venous ulcers   •Measure #5: Patient education regarding long term compression therapy   •Measure #6: Offloading of diabetic foot ulcers   •Measure #7: Patient education regarding diabetic foot care   These proposed measures next go from the AMA PQRI Work Group to the full Consortium of the AQA and from there to CMS. CMS must adopt measures it can implement, for the technical reasons outlined above. For example, while it is a laudable goal to want to decrease certain activities, which might be wasteful (like swab cultures), implementing overuse measures will be extremely difficult from a reporting standpoint. Keep in mind that some sort of code will have to be created for every chosen measure (a code to understand both the “denominator” and the “numerator,” that is, the patients who represent the population of interest, and the intervention you wish to follow).

Getting on Board

  If you are getting the idea that the measurement of “quality” is a little like defining “art,” then you are right. Recently there was a news story about a baby elephant whose abstract paintings were fetching high prices to support the local zoo. As far as I can tell the elephant art creations are indistinguishable from the human abstract variety. Perhaps measuring “quality” in medicine is just as difficult. For example, as pointed out by the recent JAMA article by Wharam, Pay for Performance does not typically assess diagnostic skill or clinician empathy, traits that patients value highly. Since quality medical care is a highly complex and individual process, we can only create surrogates for the measurement of quality. Nevertheless, we agree that there are some basic types of care which ought to be provided to patients (diabetics need eye and foot exams, women need mammograms, etc.). The Institute of Medicine’s definition of quality is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes. The challenge is that while for patients are cared for as individuals, the system must be impacted for the entire population.   Improving basic care saves money and lives. If we can provide the care, then we ought to be able to measure that it was done, and if we can measure it then we can reward performance. Part of this author rebels at a system that harkens back to pre-school days (“I got a gold star today.”). However, somewhere along the way, we failed to incorporate “quality” as a fundamental principle in our approach to medical care. We offer sophisticated care but not consistently good care, so renal failure patients may be more likely to get a transplant than a flu shot. The result has been a national scourge of medical errors, medical omissions, and inconsistent care. It is not surprising that payers have stepped in to rectify this. The take home message is that, however flawed the “quality movement” may be, we need to improve quality medical care for our patients. The various programs described here will impact your bottom line (revenue) so hospitals and providers need to get ready for them. Caroline is currently co-editor of TWC and a Board Member of the Association of Wound Care. Fife is the Director of Clinical Research at the Memorial Hermann Center for Wound Healing, Houston, Tex. She can be reached at cfife@intellicure.com.

References

1) Linking Public Accountability to Quality Improvement By Kristine Martin Anderson and Kathryn Schulke, Hospital and Health Network newsletter, https://www.hhnmag.com/hhnmag_app/jsp/articledisplay.jsp?dcrpath=HHNMAG/Article/data/11NOV2008/0811HHN_FEA_QualityUpdate&domain=HHNMAG 2) PQRI: https://www.cms.hhs.gov/pqri/ 3) 2007 PQRI Experience: https://www.cms.hhs.gov/PQRI/Downloads/PQRI2007ReportExperience.pdf