Let’s start with a non-trivial trivia question: What disease kills an American every two minutes, is implicated in as many as 50% of hospital deaths and is the most expensive condition treated in US hospitals?
For many of our healthcare savvy readers, you likely identified sepsis as the correct answer. But for the general public this is a largely unknown condition, despite accounting for nearly $24 billion in hospital costs per year and more deaths than prostate cancer, breast cancer and AIDS combined.1,3 Somewhat bewilderingly, a recent Sepsis Alliance survey found that fewer than half of Americans were familiar with this devastating and costly disease.
With Sepsis Awareness Month right around the corner, we wanted to shine a light on the condition and, particularly, the unique role care variation plays in the high cost and poor outcomes that are all too common. Of course, we also want to share some success stories.
Regional variation in sepsis mortality has been reported since 2010 when Wang et al. were among the first to identify a sepsis mortality “belt” of 11 adjacent states in the Southeastern and mid-Atlantic US with a 30% higher sepsis mortality incident rate ratio. Wang and other authors have attempted to explain the regional variation, but have fallen short of identifying a single cause. However, new data is suggesting that variation in care practices between facilities and between individual providers is likely playing a role.
In 2011, Lagu, et al published national data showing wide variation in sepsis spending and adjusted mortality rates between hospitals, but no correlation between the two. That means that spending more money on sepsis care didn’t lead to better survival. Peltan et al.’s article this summer in Critical Care Medicine drilled even more specifically into variation in sepsis care at the individual provider level. The authors identified wide variation between individual providers at a given facility in, among other things, how quickly sepsis patients were started on an antibiotic (a strong predictor of improved outcomes). Peltan’s results present an excellent view into unwarranted variation, which we define as deviations from the most effective and/or efficient care paths without a compelling patient-specific reason for that variation.
Reducing this unwarranted variation, between providers and facilities, would go a long way to saving lives and money. It is easy to think clinical variation is uncontrollable, but in our performance improvement work with health systems around the country, we’ve found variation can be successfully addressed. One of the keys to reducing unwarranted variation is to create a safe, fair and transparent space to engage providers in meaningful discussions of unwarranted variation, that does not trigger defensiveness or claims that “my patients are sicker.” One of the keys to creating this space, we’ve found, is to remove patient variability by having all providers care for consistent clinical simulations, allowing everyone to focus exclusively on variation in clinician decisions made by them and their peers in the same situations. This makes variation in a group more tangible and apparent to providers, helping them truly acknowledge, accept, and address it. While this is not a simple task, it is precisely the work we’ve shown drives real and sustainable improvements in care quality and cost effectiveness.
As the studies above show, sepsis care is a huge opportunity to improve survival and reduce the total cost of care through improved care standardization and adherence to evidence-based guidelines. Current research continues to strongly support the claim that increased compliance with guidelines is associated with reduced mortality in patients with sepsis, severe sepsis or septic shock., The focus of recent sepsis guidelines has been on early identification and treatment, before the disease increases in severity. Practice standards in sepsis care have advanced greatly in recent years with development of the Surviving Sepsis Campaign’s Bundles, the quick sepsis-related organ failure assessment (qSOFA), and the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). Focus on clinician practice adherence to these internationally recognized standards should be core to every sepsis performance improvement program.
Helping physicians recognize and reduce their sepsis care variation can play a big role in improving outcomes in this silent killer. Sepsis Awareness Month is coming up. We encourage you to take steps and find out how many of your docs are consistently following the guidelines and offer tools and solutions to help them more consistently apply them in practice.
 Sepsis Alliance Launches New Tools and Resources for Sepsis Awareness Month 2017, June 1, 2017. http://www.sepsis.org/sepsis-alliance-news/new-tools-resources-sepsis-awareness-month-2017/
 Liu, et al. Hospital Deaths in Patients With Sepsis From 2 Independent Cohorts, JAMA. 2014;312(1):90-92. doi:10.1001/jama.2014.5804, http://jamanetwork.com/journals/jama/fullarticle/1873131
 HCUP Statistical Brief #20, May 2016. National Inpatient Hospital Costs: The Most Expensive Conditions by Payer, 2013, https://www.hcup-us.ahrq.gov/reports/statbriefs/sb204-Most-Expensive-Hospital-Conditions.jsp
 Sepsis Awareness Month: Fewer than Half of Americans Have Heard of this Devastating Illness, https://www.cdc.gov/media/releases/2014/s0903-sepsis-awareness.html
Damiani E, Donati A, Serafini G, Rinaldi L, Adrario E, Pelaia P, et al. (2015) Effect of Performance Improvement Programs on Compliance with Sepsis Bundles and Mortality: A Systematic Review and Meta-Analysis of Observational Studies. PLoS ONE 10(5): e0125827. https://doi.org/10.1371/journal.pone.0125827
 Guo et al, Compliance with severe sepsis bundles and its effect on patient outcomes of severe community-acquired pneumonia in a limited resources, Arch Med Sci. 2014 Oct 27; 10(5): 970–978. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4223141/
When we talk about expensive devices in health care, the conversation often revolves around things like proton beam therapy (>$100M per installation), transcatheter aortic valve replacement ($30,000 per device) or the latest MR machine ($5M for a combined PET/MR). Non-devices also make the list. For example, high-cost drugs may creep into the conversation, such as the hepatitis C cure Harvoni ($94,500 for a 12-week course) or some of the latest cancer therapies (over $100,000 per year). One could even go so far as to say that the multi-million dollar EHR installs are the most expensive devices out there.
When it comes to total dollars spent, however, the most expensive device is actually a much smaller and more ubiquitous one: the physician’s pen.
This quip has been making the rounds health care policies circles for a about a decade, although the 21st century version is probably closer to a physician’s mouse-click rather than an actual pen. But a basic truth is at the core: physicians influence a truly enormous portion of every dollar spent on health care. Estimates place about 80% of health care spending under the control of physicians, accounting for $2.6 trillion dollars per year (1).
While there are certainly other drivers of cost (including high unit costs, patient lifestyle choices and administrative overhead), physicians ultimately wield huge influence over where and when health care dollars are spent. Physicians make hundreds of common, important decisions every day, such as whether to admit a pneumonia patient to the floor or the ICU, which chemotherapy combination to prescribe to a lung cancer patient, or whether to order an MRI for a back-pain patient. These have huge cost implications for payers and employers and increasingly for all of our patients.
There’s a mountain of evidence that physicians spend wildly different amounts when they take care of the same patients. To underscore the randomness, those $2.6 trillion physician-controlled dollars are not tied to better patient outcomes. For example, a recent Health Affairs article from researchers at the University of Michigan found that some hospitals were 6.5 times more likely to admit a non-specific chest pain patient than others, with no impact on mortality up to two years later (2). Variation also exists between providers at the same organization. A JAMA article last month found that higher spending by hospitalists at the same organization did not result in lower 30-day readmissions or mortality rates for their patients. Interestingly, they also found that variation in case-mix adjusted spending was actually more significant between physicians within the same hospital than between the average difference between hospitals (3).
Obviously, the opportunity to change physician decisions and lower costs, could be low hanging fruit compared to other cost reductions, elimination of expensive devices or even reducing access. Influencing and changing physician behavior to reduce spending variation can be very difficult. Notwithstanding, it lies at the core of everything health care leaders are asked to do in today’s cost-reduction-quality-improvement-enhanced-access world.
We all believe that physicians want to do the right thing for patients, but ingrained practice patterns, evolving guidelines, lack of visibility into total cost of care and absence of real-time feedback with useful information leads to inefficient, costly and potentially dangerous variation.
At QURE, using our unique Clinical Performance and Value (CPV) case simulations, we have been able to both measure that variation and change it through targeted feedback and facilitated group discussions. The CPVs give us the chance to have all providers care for the exact same patient and collaboratively discuss how to reduce that variation as a group. Here are a few examples of the impact this approach can have:
- Primary care: In a large ACO, we found that 70% of heart failure patients with symptoms that should be easily managed primary care setting were being referred on to cardiologist. Over multiple rounds of engagement, that was reduced to 9%, saving an estimated $6.2 million dollars in unneeded specialist care and work-up.
- Oncology: With a large group of medical oncologists, we found that only 27% were including palliative/supportive care measures in their initial treatments for late-stage lung cancer patients. Working together with the group, that number rose to 61%, saving an estimated $2.7 million dollars.
- Hospitalists: Recognizing sepsis early, and administering guideline-line based therapy is the most effective way to save both lives and money with this common and costly condition. In our work with hospitalists, we have seen a 15% improvement in primary diagnosis rates for sepsis patients, saving an estimated $1.3M for every 1,000 sepsis patients seen.
The physician keyboard/mouse is a powerful device that saves countless lives every day. When used judiciously and purposefully, it can be equally effective at saving money and lowering costs. We would look forward to talking with you about how QURE can help you maximize the important power your physicians wield. Contact us at QUREsupport@qurehealthcare.com or call us at 415-321-3388.
QURE Healthcare is pleased to announce Scott Pope, PharmD has joined as company Vice President of Strategy and Solutions. Dr. Pope brings a deep background in healthcare quality performance improvement and a proven track record of rapidly growing market penetration for numerous healthcare innovations. In addition to his clinical experience as an infectious diseases pharmacist, for more than a decade Scott has helped health systems, life science companies, and outcomes research efforts provide safer, better and more cost-effective healthcare.
As QURE Healthcare continues to expand, Dr. Pope will lead the go-to-market strategies and sales initiatives for QURE’s unique Clinical Performance and Value (CPV®) vignettes.
“We are thrilled to welcome Dr. Pope to the QURE team. Scott shares our mission to engage physicians and transform clinical care. His unique skills as a clinician and sales director are a differentiator for the future of our business. I am delighted that Dr. Pope will be able to impact the care of more patients with our CPV® technology by joining our organization,” said Dr. John Peabody, QURE’s President and Founder. “Scott’s extensive experiences in both clinical practice and the business of delivering better healthcare are a formidable pair and the perfect combination to help us reach our growth goals.”
“My career has been dedicated to advancing the adoption of processes, technologies, products, and collaborations that produce higher quality, lower cost healthcare. In that spirit, there is an abundance of peer-reviewed data clearly demonstrating the ability of the QURE approach to reduce costly care variation and doing so in a way that physicians and other providers embrace,” said Dr. Pope. “QURE’s solutions are a tried, true, and flexible means for helping health systems reach many of their current cost and quality objectives. I am elated to join the QURE family and responsible for expanding the adoption of a solution that is precisely what healthcare is seeking.”
Dr. Peabody added, “QURE has strategic partnerships with some of the most thoughtful Fortune 500 companies. As we grow in this area QURE needed senior leadership in sales, business development, and marketing to guide these vital relationships—relationships we expect to use as we transform clinical care in every hospital and every sector we engage.”
About Scott D. Pope, PharmD
Dr. Pope sparked his career with nearly a decade at Premier, Inc. (NASDAQ: PINC) in a wide range of roles with increasing responsibility in sales, marketing, new business development, monetizing intellectual property, and new product commercialization. He most recently comes from Northwestern Capital Partners, LLC where he headed up clinical due diligence processes, designed go to market strategies for portfolio companies, and recruited new portfolio prospects. Pope holds a PharmD and minor in business administration from Ohio Northern University. He completed a pharmacy practice residency at Moses Cone Memorial Hospital and a specialty residency in infectious disease, internal medicine, and academics through Campbell University at Duke University Medical Center. (https://www.linkedin.com/in/scottdpope/)
In one of the most stunning political upsets in a generation, Donald Trump was elected to the Presidency. One of Trump’s favorite targets on the campaign trail was Obamacare (the Affordable Care Act [ACA]), which he promised to repeal. Although his rhetoric has softened somewhat after the election, opening the door for portions of the ACA to remain in place, Trump’s win combined with Republican control of both the House and Senate likely mean a number of significant changes in the months and years to come. Healthcare executives across the country are in a difficult position as they attempt to plan for the changes ahead and control risk in an environment of ambiguity. One impact of this uncertainty can be seen in stock prices: shares of HCA fell 11%, Tenet fell 25% and Community Health Systems fell 22% the day after the election and have not returned to their pre-election levels.
Last week brought some new signals of what might happen in 2017 and beyond after Mr. Trump announced he was nominating House lawmaker and former orthopedic surgeon Tom Price (R-Ga.) to lead the Department of Health & Human Services (HHS) and Seema Verma, a healthcare consultant, to serve as Administrator for the Centers for Medicare and Medicaid Services (CMS). Both appointments communicate a clear signal of Trump’s intention to reshape the ACA and Medicare/Medicaid in this country with potentially far reaching impacts on health reform, access and payment.
In evolving and uncertain times, it can be helpful to return to three principles and chart a course from there. First, we know healthcare is too expensive in the US—one of the only policy items where Republicans and Democrats both agree. Second, the focus of repealing Obamacare will be on access to care and less so on the delivery of care, where cost and quality will remain ascendant challenges. Third, patients and payers want high-quality care and sophisticated tools to demonstrate their quality. Anchoring on these three truths supports QURE’s fundamental premise that providers and health systems that want to succeed in this uncertain environment must remain focused on delivering value – the highest-quality care at the most efficient price.
Below we outline a few insights on what these developments likely mean for healthcare reform, payment and innovation.
What Do Trump’s Appointments Tell Us about the Future?
Representative Price currently serves as chair of the House Budget Committee and sits on the Health Subcommittee of the House Ways and Means Committee. Like Mr. Trump, Dr. Price has expressed his opposition to the ACA, but unlike the President-elect, he has proposed specific policy changes through bills sponsored in Congress. One such bill, HR2300, would repeal the ACA, eliminate the individual mandate and provide tax credits based on age to purchase health coverage. Price’s proposed bill would also set limits on tax exclusions for employer-sponsored plans and allow insurers to sell coverage across state lines—a provision that Trump has also endorsed on the campaign trail. Price is also in favor of giving states increased control over Medicaid funding through federal block grants based on a per capita funding formula.
Price was a supporter of the Medicare Access and CHIP Reauthorization Act (MACRA), which provides a strong impetus for providers to move towards value-based care. He has, however, criticized the mandatory programs and reporting requirements that came out of the Centers for Medicare and Medicaid Innovation (CMMI). In September 2016, Price was the primary signatory on a letter from a group of 178 House Republicans and one Democrat asking CMS Administrators to “cease all current and future planned mandates” under CMMI.
Seema Verma, who was running a health policy consulting firm, made a national name for herself in Vice President-elect Mike Pence’s home state of Indiana where she helped broker a deal for Medicaid expansion. Like Price, Verma is a strong proponent of giving states expanded flexibility with Medicaid and supports expanded use of personal Health Savings Accounts (HSAs) to give consumers more control and responsibility for healthcare spending.
Factors Keeping the Focus on Value
While many questions remain, last week provided some important insights into Trump’s potential path forward. Here we highlight four trends, not meant to be exhaustive, indicating that high-value care will remain the important differentiator for successful health systems and providers:
- Greater consumer responsibility for health spending: The existing trend of shifting costs to consumers and patients is unlikely to be slowed by any of the proposals set forth by Trump or his team. In fact, greater use of tax credits and HSAs is only likely to accelerate this shift. An increasing array of online tools is making it easier for consumers to identify lower cost providers and differentiate based on quality. As more of the cost of care comes out directly out consumers’ accounts, expect continued shifts away from high cost providers, such as the shifts we are seeing in elective outpatient imaging.
- Sustained pressure on Medicare spending: Medicare makes up 15% of the federal budget today and is unlikely to see support for large spending increases from Dr Price or Mrs. Verma. Even as specific programs change and evolve within CMS, controlling costs will continue to be a priority for the new administration, especially with Representative Ryan leading the House.
- Continued demand for high-value, low-cost healthcare from employers: Over half of all Americans get health insurance through their employers, and these employers are feeling crushed by rising costs. Regardless of what occurs in Washington, employer focus on controlling costs, such as high deductible plans, will remain a key component in healthcare selection.
- More competition among payers: Changes such as allowing interstate sales of health insurance products is likely to drive competition among payers for increasingly price-sensitive consumers and cost-conscious employers. This competitive environment will drive continued growth of emerging plan structures, such as tiered-benefits and narrow networks that seek to reward high value providers and punish high-cost, highly variable ones.
- Increased experimentation at the state level: One of the mantras of those advocating repeal of the ACA has been for increased control at the state-level, especially for Medicaid. Paying attention to your local state environment is likely to be even more important in the coming months and years. We will likely see strong success stories, and some failures, that will hopefully provide lessons for the whole nation.
With these changes there will be winners and losers; not even the Trump administration knows the exact details of how this will unfold. We do know, however, that pressure to control costs will continue to come from inside and outside of Washington. We also know that variability in quality and cost is becoming a large influencer of both payment decisions and patient choice. Legislation and existing regulation, like MACRA, already create the impetus for moving away from a fee-for-service world, and Republican legislatures will need to figure out how to either refocus or build on existing successes in transitioning to a value-based environment. One of the most important parts of any plan to improve quality and reduce costs is engaging physicians in the process of standardizing care. If you are interested in how QURE’s proven CPV engagement approach can help you work with your physicians to improve value in an uncertain environment, give us a call today.
Our recent publication that came out last month which highlights our results managing breast cancer in a multi-center trial that included 81 oncology practitioners across two NCI-accredited institutions, a multi-hospital system and a community based practice.
Highlights of the results include:
- On average, breast cancer patients represented about 46% of the participating clinician’s patient panel; and the average percentage of time teaching was 14.2%
- Baseline mean scores did not differ among the four sites, but significant variation was seen within each site at baseline.
- Between baseline and the 4th round of cases and feedback, overall mean quality scores increased at each site. The size of the increase ranged from 14 to 70% (P<0.01)
- Each of the domain scores (history, physical, workup and Dx/Tx) also increased significantly from baseline
- Variation decreased at all sites in all domains
- Variation in areas of specific clinical interest (surgical decisions, axillary management, radiation therapy, chemotherapy and hormonal therapy) were identified and showed improvement.
Check out the publication here .
In early May, researchers from John Hopkins University published a study in The BMJ which estimated that medical errors lead to over 250,000 deaths in the United States each year (Makary and Daniel, 2016). Many of you will recall the landmark IOM report in 1999, which reported that there were 98,000 unnecessary deaths, erupting into a national uproar about poor quality of care in America (Kohn, Corrigan, and Donaldson, 2000). Fifteen years on, the number is even higher making medical error the third leading cause of death, surpassing common diseases like COPD, stroke and Alzheimer’s. Errors in diagnosis account for a significant portion of these medical errors; one study estimated that diagnostic errors account for nearly 30% of all paid malpractice claims (Tehrani, Ali S. Saber, et al. 2013). David Newman-Toker, MD, PhD, a lead researcher in this area, observed that “diagnostic errors could easily be the biggest patient safety and medical malpractice problem in the United States.”
Diagnostic errors, which occur when a diagnosis is missed, identified incorrectly or delayed, can have a significant impact on the cost and quality of care. In a best case scenario, treatment is delayed or applied inappropriately, leading to increased cost or inconvenience. In a worst case scenario, missed or incorrect treatment leads to significant morbidity or even death. In fact, researchers estimate that the number of misdiagnosis-related claims that cause preventable, permanent damage or death may be as high as 160,000 each year (Newman-Toker et al. 2013).
These studies highlight a serious, persistent problem which the health care community has struggled to address. In this newsletter, we will tackle this complicated issue by outlining difficulties measuring diagnostic errors and exploring a unique approach to improving clinical practice and preventing diagnostic errors.
Difficulties Measuring Diagnostic Errors
Not surprisingly, current tools to detect and study diagnostic errors are often inadequate. Current electronic medical records are not designed to easily flag these errors, longitudinal chart abstraction can be cumbersome and resource intensive, and patient registries are costly to set up and maintain. However, some researchers are taking creative approaches to quantify the problem at the population level. One group reports that misdiagnosis rates in the U.S. typically average 15% (Bernes and Graber 2008). QURE’s own work has found that clinicians miss the patient’s primary diagnosis approximately 18% of the time, with the highest misdiagnosis rates found in cancer. A 2009 AHRQ report found that 28% of 583 diagnostic mistakes reported anonymously by doctors were life-threatening or had resulted in death or permanent disability (Schiff et al 2009). Another study found that one in ten autopsies uncovered some disease or condition that—had its existence been known when the patient was alive—would have altered his or her care or changed the prognosis (Shojania et al 2003).
At the individual health system and facility level, addressing the problem of missed diagnoses is even harder. Typically, measuring diagnostic errors requires extensive review of a patient’s chart or lengthy follow-ups. Even then, a diagnostic error may not be identified for years, potentially after a series of inappropriate treatments are revealed to be ineffective.
Since measurement of diagnostic error is difficult, most health system and clinical leaders have little understanding of their internal diagnostic error rates and the types of clinical cases most likely to lead to errors. In a 2015 report on diagnostic error, the Institute of Medicine’s Committee on Diagnostic Error in Health Care recognized the need to develop new “approaches to monitor the diagnostic process and to identify, learn from, and reduce diagnostic error” (IOM, 2015). Newman-Toker thinks that most clinical leaders are actually aware of the problem but are “afraid to open up a can of worms they couldn’t close” (Johns Hopkins Medicine 2013). Internist Mark L. Graber, founding president of the Society to Improve Diagnosis in Medicine, further claims that he is unaware of “a single hospital in this country trying to count diagnostic errors” (Boodman 2013).
Unique Approaches to Measure and Improve
Approaches that target system issues are needed to address diagnostic error. System issues include barriers preventing clinician communication, coordination and handoffs. There are also practice issues. A diagnosis is a collective clinical effort that in today’s practice typically involves a team of health care professionals — from primary care physicians, to nurses, to pathologists and radiologists. Research indicates that enhanced communication and collaboration among treating health care professionals can significantly improve diagnostic accuracy (IOM 2015). QURE’s own experience with an NCI-designated cancer center found diagnosis scores increased by 49% after members of the multidisciplinary care team came together to develop and implement a common set of diagnostic and treatment pathways. In this case, QURE’s Clinical Performance and Value (CPV) vignettes were used to identify gaps in care for pathways development and then measure compliance with the pathways through constructive feedback on performance across a multidisciplinary team.
For hospitals looking to understand, measure and reduce common diagnostic errors, research conducted by AHRQ has found that case-specific vignette simulations can be an effective tool to tackle this difficult issue (Converse et al., 2015). AHRQ cites a number of advantages of using simulated patient vignettes to measure care quality and identify behaviors that lead to diagnostic error. These advantages include controlling for patient variation, rapidly gathering data on practice patterns without the need for chart abstraction, avoiding challenges of incomplete patient data and the ability to generate large sample sizes to study variation in practice (Converse et al., 2015). The unique advantage of the simulated case is that the diagnosis is known with certainty (Peabody et al., 2016)
Other methods of delivering feedback on potentially missed diagnoses, such as notifying physicians when a patient discharged from the hospital is subsequently readmitted with a different diagnosis are retroactive, can be difficult to implement in a meaningful way, and may come at the patient’s expense and health (Eva and Norman, 2005). Again, simulations offer specific advantages and provide proactive learning and feedback to improve diagnostic capabilities. Since the characteristics and ultimate diagnosis of the patient is known in a simulation, systems can objectively measure diagnostic error rates and provide feedback on the missed signs and cognitive miscues that led to the error. Practice data generated from vignettes can be used to quickly provide practicing clinicians with feedback on the appropriateness of the work-up that led to that diagnosis. All this can be done without harming patients or laboring through exhaustive chart reviews.
Vignettes also have the advantage of fostering group discussions that are anchored in specific clinical scenarios, rather than hypothetical case anomalies. Only with vignettes can everyone take care for the exact same patient and then talk about why they did things differently, learning together along the way. These discussions can be key to creating a group collaborative culture, which research suggests has the potential to significantly improve diagnostic accuracy by facilitating conversations among clinicians about individual diagnosis (IOM 2015, Schiff et al. 2005).
Diagnostic error is a significant issue in US health care delivery, leading to poor outcomes and high costs. Despite this physical and economic burden, diagnostic errors are often overlooked because they are difficult to measure, and even harder to improve. However, unique and innovative approaches (such as QURE’s CPVs) offer a rapid, scalable tool to not only measure diagnostic errors at the individual clinician level, but also deliver personal and group feedback to improve performance.
For health systems, physician groups and payers looking to deliver the best possible care for patients, minimize risk and succeed in a value-based payment world, a comprehensive approach to understanding diagnostic pitfalls and getting the right diagnosis the first time is essential.
Berner, Eta S., and Mark L. Graber. “Overconfidence as a cause of diagnostic error in medicine.” The American journal of medicine 121.5 (2008): S2-S23.
Boodman, Sandra. “Misdiagnosis is more common than drug errors or wrong-site surgery”. The Washington Post. May 6, 2013.
Committee on Diagnostic Error in Health Care; Board on Health Care Services; Institute of Medicine; The National Academies of Sciences, Engineering, and Medicine; Balogh EP, Miller BT, Ball JR, editors. Improving Diagnosis in Health Care. Washington (DC): National Academies Press (US); 2015 Dec 29. 9, The Path to Improve Diagnosis and Reduce Diagnostic Error.
Converse L, Barrett K, Rich E, Reschovsky J. Methods of observing variations in physicians’ decisions: the opportunities of clinical vignettes. J Gen Intern Med. 2015 Aug;30 Suppl 3:S586-94.
Kohn L T, Corrigan J M, Donaldson MS (Institute of Medicine) To err is human: building a safer health system. Washington, DC: National Academy Press, 2000
Newman-Toker, David E., and Peter J. Pronovost. “Diagnostic errors—the next frontier for patient safety.” JAMA 301.10 (2009): 1060-1062.
Newman-Toker, David E., et al. “How much diagnostic safety can we afford, and how should we decide? A health economics perspective.” BMJ quality & safety 22.Suppl 2 (2013): ii11-ii20.
Peabody, John W., David R. Paculdo, Diana Tamondong-Lachica, Jhiedon Florentino, Othman Ouenes, Riti Shimkhada, Lisa Demaria, and Trever B. Burgon. “Improving Clinical Practice Using a Novel Engagement Approach: Measurement, Benchmarking and Feedback, A Longitudinal Study.” J Clin Med Res Journal of Clinical Medicine Research 8.9 (2016): 633-40. Web.
Phillips, Lauren. “Rooting Out Diagnostic Error in Health Care.” The Healthcare Finance and Management Association. Feb 10, 2016. http://www.hfma.org/Leadership/Archives/2016/Winter/Rooting_Out_Diagnostic_Error_in_Health_Care/
Schiff, G.D., Kim, S., Abrams, R., Cosby, K., Lambert, B., Elstein, A.S., Hasler, S., Krosnjar, N., Odwazny, R., Wisniewski, M.F. and McNutt, R.A., 2005. Diagnosing diagnosis errors: lessons from a multi-institutional collaborative project.
Schiff GD, Hasan O, Kim S, et al. Diagnostic Error in Medicine: Analysis of 583 Physician-Reported Errors. Arch Intern Med. 2009;169(20):1881-1887. doi:10.1001/archinternmed.2009.333
Shojania, Kaveh G., et al. “Changes in rates of autopsy-detected diagnostic errors over time: a systematic review.” Jama 289.21 (2003): 2849-2856.
Tehrani, A. S. S., Lee, H., Mathews, S. C., Shore, A., Makary, M. A., Pronovost, P. J., & Newman-Toker, D. E. (2013). 25-Year summary of US malpractice claims for diagnostic errors 1986–2010: an analysis from the National Practitioner Data Bank. BMJ quality & safet
Take a look at QURE’s latest peer-reviewed publication, “Improving Clinical Practice Using a Novel Engagement Approach: Measurement, Benchmarking and Feedback, A Longitudinal Study.” The study demonstrates how CPVs measure variation in breast cancer care across multiple health systems and, through individual and group feedback, drive significant improvements in adherence to evidence-based care and clinical pathways.
Read it here.
Check out this Medscape article featuring an interview with Dr. John Peabody, QURE’s President, discussing how Medicare’s new MIPS program is part of a larger move towards prioritizing value, and paying physicians accordingly.
The article is available here.
A little over a year ago, Health and Human Services (HHS) secretary Sylvia Burwell announced the goal of tying 30% of payments to quality or value by the end of 2016 . This March, the Centers for Medicaid and Medicare Services (CMS) announced that they had achieved that goal– nearly one year ahead of schedule . CMS attributed the success to a jump in the number of new accountable care organizations (ACOs) and increasing participation of providers in alternative payment models like medical homes and bundled payments. The next milestone of 50% by 2018 is now looking more like an inevitable reality as CMS becomes more aggressive with the shift to value-based care. Mandatory programs like the bundled payment program for hip and knee replacement (known as CCJR) are a sign of the times to come as CMS continues to accelerate the shift towards value-based care.
Much of the framework guiding CMS’ new aggressive push towards value based care is an important piece of legislation signed into law last April by President Obama . The legislation, known as the Medicare Access and CHIP Reauthorization Act, is commonly referred to as MACRA. MACRA codifies how CMS will drive payments based on the quality of care delivered rather than the volume of services (e.g. procedures, visits, tests) provided. MACRA creates a new Merit-Based Incentive Payment System (MIPS) which combines the Physician Quality Reporting System (PQRS), Meaningful Use (MU) EHR incentive program, and Physician Value-Based Modifier into a single payment adjustment. Although MIPS will not directly impact payments 2019, it might just be the law that makes or breaks providers.
Breaking down MIPS
MIPS measure providers in four performance categories: (1) Quality (2) Resource Use (3) EHR Meaningful Use and (4) Clinical Practice Improvement Activities (CPIA). The MIPS quality measurement score continues to mandate PQRS reporting but will use an expanded list of quality measures. CPIA is potentially a powerful idea that assesses physicians in categories like population management, care coordination, practice assessment and steps taken to expedite future participation in alternative payment models. Interestingly, measurements of efficient resource utilization will triple in importance over the first three years of MIPS (from 10% to 30% weighting in the MIPS formula), signaling an added focus by CMS on the elimination of wasteful practices and procedures. See below for weights in the respective four categories.
An Alternative to MIPS is Available: The Alternative Payment Models Track
MACRA stipulates that providers may opt out of MIPS if they participate in an “Alternative Payment Models” (APMs) which can include a number of options including Multi-Physician bundled payments, episode-based payments and condition-based payments. Between 2019 to 2024, APM participating providers will be eligible to receive a 5% annual lump sum bonus on the physician’s fee schedule payments. To qualify, however, providers must meet increasing thresholds for the percentage of their revenue they receive through qualifying APMs.
What should physicians do now?
Embrace Individual Performance Data and Transparency: The new MIPS system will focus on giving a single score to each individual physician. All MIPS scores and individual category scores will be posted on the CMS Physician Compare website. The posted scores will show where providers fall in the distribution of their peers across the country.
Health systems and physician groups, who understand the implication of MIPS, will need to start thinking of efficient ways to measure individual performance data today and prepare their physicians to succeed under the new rules. Under PQRS, groups that did not report data only stood to lose two percent of their revenue. Under MIPS, however, that potential lose could jump to nine percent, depending on how well they score in the four performance categories. On the other hand, physicians who score extremely high, will also be eligible for a 27% payment bonus over a three year period under MIPS . Physicians will not only need to get used to getting measured but also having their performance available to consumers as CMS moves towards using transparency to improve performance.
What should hospitals do now?
Prepare their Providers for Culture Change (A Shift Towards Value-Based Care): Some components of MIPS, such as PQRS, already support elements of group performance reporting to CMS. However, as mentioned previously, most of the quality measures are collected on an individual basis. Hospitals will need to better understand how individual performance of docs is affecting the group and will need to foster a collective culture shift towards measurement and value-based-care. These strategies should focus on specific opportunities for improvement and delivered in a way that is non-threatening, while emphasizing the consequences of falling behind on the road to value based care. Providers are already overwhelmed with existing compliance burdens and MACRA should be presented as a piece of legislation put in place to facilitate the move towards value based care.
A simple approach to system engineering for quality are simulations. The Agency for Healthcare Research and Quality (AHRQ), through the consulting firm, Mathematica, concluded the same . AHRQ sought a reliable measure of care-process that could be conducted across groups of providers which could serve as important feedback on performance. AHRQ’s conclusion was that simulations, similar to the validation work QURE has conducted, is the best available, most robust option for engaging providers and identifying variation.
With the passage of MACRA, the federal government has made it clear that the move to value-based care will proceed at an even faster pace. At the same time, CMS is demonstrating a continued willingness to work with providers to achieve these goals using multiple approaches as they seek the best way to pay for and deliver value-based care. One of the key messages from HHS is that it intends to make traditional, volume-based fee for service payment less profitable and more challenging. Providers who embrace value-based payment early and develop a culture of transparency, accountability and adherence to evidence-based guidelines stand a much better chance of thriving through this transition. Health care systems and physician organizations need to tools to prepare their physicians for these changes, and MACRA and MIPS only accentuates this need. QURE’s innovative CPV physician engagement platform has been designed and validated to change physician behavior, improve quality and reduce costs. If your organization needs help preparing your physicians for success, let’s set up a conversation to discuss how QURE can help standardize and elevate your clinical practice.
On April 1, mandatory bundled payments arrived in orthopedics for lower-extremity joint replacement (LEJR). The Comprehensive Care for Joint Replacement (CCJR) bundled payment program is the first of its kind but there is every indication that CMS will use similar compulsory models in other clinical areas very soon. Understanding and adapting to CCJR will prepare you for these future changes to come. The question, then, is what is the best way to respond?
The CCJR bundle mandates that approximately 800 hospitals across the country assume financial risk for the cost and quality of a complete, 90-day episode of care. The episodes start on the first day of admission and extend through post-acute care for hip and knee LEJRs (MS-DRGs 469-470).
In other words – hospitals are now the payer. They are on the hook not only for the inpatient costs of care but also physician reimbursement and post-acute facility care in skilled nursing facilities, long-term care hospitals, rehabilitation centers and home health within that 90-day period. If hospitals can keep total costs under the target bundle reimbursement they ‘win,’ earning dollars for the difference; they can also add to the win and receive a bonus by earning quality-based performance payments. However, if costs exceed target bundle prices, these hospitals ‘lose’ and must pay CMS back the difference. With so many factors impacting success in CCJR, what are hospitals to do? The answer: engage physicians now and elevate the care they provide to this patient population.
The driving rationale behind CCJR and forthcoming bundled payment models is enhancing the VALUE in healthcare, i.e. providing the highest quality care at the lowest possible price. LEJRs are one of the most common and expensive surgeries incurred by Medicare beneficiaries and the variation in care and outcomes is well documented. For some hospitals, over half of LEJR costs are actually incurred after the patient leaves the hospital, in the post-acute setting. CCJR was designed to incentivize hospitals to work closely with their physicians to reduce the variation in how LEJRs are performed and improve post-procedure care and outcomes. In the LEJR care path, physicians have responsibility for developing best practices based on the evidence base, coordinating and managing several aspects of patient care during surgery and recovery, and ensuring their patients are discharged to an appropriate level of post-acute care.
Physician adherence to best practice standards greatly impacts post-surgical complications and LEJR bundled costs. According to the American Joint Replacement Registry, approximately 70% of LEJR surgical revisions occur within 3 months of the initial surgery, with infection and inflammation being the most common causes of readmission. There is readily-available guidance from the National Surgical Infection Prevention program (2004), Surgical Care Improvement Project (2006) and American Association of Hip and Knee Surgeons (2013) on pre-operative, prophylactic antibiotic infusion that can prevent these infections from occurring. Adherence to evidence-based medicine, however, is poor and the best guidance and protocols have minimal impact if they are not put into practice.
Thus, hospitals must engage their physicians and facilitate alignment around evidence-based pathways to make it under CCJR. QURE’s President, John Peabody, MD, PhD, in the webinar “Demonstrating Who You Are in CCJR: Data Describes the Problem, Providers Deliver the Solution” (accessible on the QURE website here: CCJR Webinar Link) outlined how to engage orthopedic surgeons in CCJR. QURE recommends an approach that ‘Elevates the Quality of Practice Standardization’ by:
- Measuring Clinical Practice through use of an easily accessible measurement tool, such as Clinical Performance and Value (CPV®) vignettes, to capture and analyze clinician behavior and practice from intake through post-acute treatment.
- Baseline measurements, which few institutions do in enough meaningful detail, enable targeted efforts to reduce specific areas of unnecessary variation that impact cost and quality the most.
- Instilling Accountability by serially assessing individual and group-level performance and improvement on targeting areas of variation.
- Provide transparent performance scores and incentivize with CME credits.
- Facilitating Physician Behavior Change with customized feedback, education on improvement opportunities, and performance comparisons to their actual peers.
- Group level discussions focused on care variation are among the most efficient ways to standardize practice.
Practice change doesn’t happen overnight. Hospitals will have to begin to lay the foundation for stronger provider engagement and practice changes in orthopedics to avoid CCJR penalties that will begin in one year. Additionally, the best hospitals will heed CJR as a clarion call to consider the changes required to engage physicians in the next targets for mandatory bundled payment (e.g. pneumonia, cardiology). Real cost-savings are only possible when physicians, the key providers of care, shift their practice towards evidence-based standards. In this scenario, hospitals, physicians AND patients win.