Bridging Business & Healthcare : Healthcare Management Consultants for Dispute Resolution, Valuation & Clinical Compliance

This week the newly appointed head of CMS, Dr. Donald Berwick, gave his first public speech since his appointment in July. As the speech opened, he mentioned a lot of the “what’s” of healthcare reform; costs must decrease, new ideas are needed, we must work together, change is imperative, etc He did not, however, mention much regarding “how” he intends to lead us there. Further into the speech however, Dr. Berwick may have given us a glimpse into his plan. He referred to a “three part strategy" to:

• Improve the experience of patient care;
• Attack population-wide causes of disease; and,
• Reduce per-capita costs of health care. 

This strategy is an apparent reference to the “Triple Aim”, a concept first promoted by Dr. Berwick following its introduction in an article published in the journal Health Affairs in 2008.

Since his appointment, Dr. Berwick has been criticized for not outlining a solid plan to implement healthcare reform. When asked how he would do just that in his original article, Dr. Berwick did have a plan. That plan included some very difficult and not very politically popular suggestions: global budget caps on total healthcare spending, measurement and fixed accountability for the health status of populations of patients, standardized measures of care and quality, sharing of financial gains with those that help reduce cost and improve quality, and training clinicians to improve their ability to change processes of care. Curiously, Dr. Berwick chose not to include any of those suggestions in his speech this week.

Over the last few months, the healthcare reform debate has been peppered with cries of things that various groups will NOT do, but no one has yet emerged as the leader who has the ideas of what we CAN do to achieve meaningful reform. Among other attributes, leadership involves establishing a clear vision, sharing that vision clearly so that others can follow, and then providing the information, knowledge and methods needed to accomplish that vision. I may not agree with every tenant of Dr. Berwick’s plan, but he at least he (at one time) had a plan. By choosing not to continue casting his vision for that plan, the opportunity to become the leader healthcare reform desperately needs may just have passed him by.

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We all have our guilty pleasures. One of mine is reading my weekly issue of Sports Illustrated cover to cover. During this time of year, every issue ends with the same column titled “Things I Think I Think” – a column dedicated to “all the latest news, buzz, and inside information”. Like all of you, I have been bombarded with buzz daily about the latest developments in healthcare reform. In an attempt to keep up, I have immersed myself in the law for the last several months, trying to make as much sense of it as I can. After taking in all of this information, and adding in a few of my own thoughts, here (so far) is what I think…I think.

• Even though I get email every day on how to be one, and the law allows for the formation of them, I don’t believe that ACOs are ready for primetime just yet. There is a lot of good that may come from them in theory, but the operational challenges of actually designing, implementing, and successfully managing an ACO are daunting at best. The complexities of actually pulling all of the moving parts together may prove too much for the majority of healthcare organizations, leaving much of what the law has set out to do a distant goal for many. 
• The pilot project that CMS has underway for orthopedics, interventional cardiology, and cardiovascular surgery is already approaching the halfway mark, with preliminary performance data expected in November of 2010. These bundled payment models are likely here to stay, at least in high dollar specialties. There are several facts that lead me to this conclusion. First, these models are designed to jointly incentivize physicians and hospitals in their efforts to deliver high quality care by removing the primary reimbursement barrier facing them today; disparate payment systems that are misaligned.  Secondly, the outcomes metrics in these specialties are well developed, and some of them have already been rolled out by CMS for public comment outside of the demonstration project to be used in other portions of the healthcare law. And last, but certainly not least, the enormous amount of financial savings that is likely to be gained by implementing these models will simply be too great for CMS and other payers to ignore.
• Physician payment reform may not come in the form of repealing the SGR, but will be greatly shaped by the Value Based Payment Modifier section of the new law. This section (section 3007) is designed to reward physicians who deliver high quality, low cost care with respect to their peers by changing the amount paid per work RVU. The metrics to be used are due out by January 2012, rule making is set for 2013, with full implementation scheduled for January 1, 2015. This may seem a long way out, but the advantage this modifier may have over other methodologies is that it avoids the need to overhaul the payment infrastructure currently in place. Once quality metrics are defined, you will simply be paid more (or less) per work RVU using the same systems that CMS currently has in place.

At the end of the day, I guess what I think I think is that even though we have a long way to go before all of the pieces of the puzzle fall into place for truly meaningful reform, we are soon to see the effects of several of these pieces,  signaling the beginning of truly significant change to our system.

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This past week, CMS announced a public comment period on several newly released quality metrics focused on stroke outcomes – 30-day all cause mortality and 30-day readmission rates. As I spend most of my day working on healthcare reform and quality, I spent the weekend diving into these metrics, wanting to be sure exactly which clinical improvements CMS was looking to incentivize physicians and hospitals to achieve. I quickly scrolled down through the 30-page “Measure Information Form,” looking to find the definition of the metric and why it was chosen. I had to go about 10 pages into the document, but there it was.  I came upon the section titled “Measure Justification” with the subtitle "Importance.” Under this impressive heading, CMS went on to say it would define this "Importance” by the "Extent to which the specific measure focus is important to making significant gains in healthcare quality (safety, timeliness, effectiveness, efficiency, equity, patient-centeredness) and improving health outcomes for a specific high impact aspect of healthcare where there is variation in or overall poor performance.” OK. Makes sense so far.

Not too much further into the document, CMS goes on to define the Summary of Evidence of High Impact. Perfect. This is just what I am looking for. Let’s see – Affects Large Numbers. I can buy that. Stroke affects almost 800,000 people every year in the U.S. Next. Leading Cause of Morbidity/Mortality. Stroke is the third leading cause of death in the U.S. after heart disease and cancer. Well said. CMS seems to be right on point. Next. Severity of Illness Stroke survivors frequently experience significant long term disability. And finally – High Resource Use. The estimated direct and indirect cost of cerebrovascular disease for 2010 is $73.7 billion. Hey, wait just a minute. I thought we were talking about improving clinical quality. How did this get in here?

When I was a young physician in training, we spent hours learning to read and interpret clinical studies, always keeping current on the latest trends to assure we were providing the best clinical care to our patients. It wasn’t that we were trained to ignore the cost of care, but we didn’t include it as we defined whether or not quality was improved. Quality was on one hand, cost on the other, and we weighed them together in our decision. Now it seems as if that line has become a bit blurred. 

In 2007, CMS released a report to Congress entitled “Plan to Implement a Medicare Hospital Value-Based Purchasing Program.” The report's goal is defined by moving more towards a value-based system of care as follows:

CMS recommends replacing the current quality reporting program with a new program that could include both public reporting and financial incentives for better performance as tools to drive improvements in clinical quality, patient-centeredness, and efficiency.

When you critically examine current demonstration projects, the trend continues. Right alongside of "Post-operative stroke” you will find "Average and median length of stay” both listed as metrics to measure quality.

When the definition of whether or not quality is achieved is dependent on the resources consumed, are we limiting our focus to only those outcomes that also provide financial savings? Has cost become the new sine qua non of quality? Maybe the new line isn’t that blurred after all….

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Friday brought about a bit of good news for cardiologists. The Centers for Medicare and Medicaid Services (CMS) released a technical correction to the Physician Fee Schedule resulting in significant increases in fees for cardiac CT, cardiac catheterization and myocardial perfusion imaging procedures. Jack Lewin provides this summary of the corrections.

This change does not completely right the ship for cardiology services, but it may slow down the rush to employment. It certainly will have a positive impact on valuation of cardiology practices that have a significant volume of ancillary services.

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