How do physicians, payers and hospitals define "quality" in spine care?
In a presentation titled "Collaborative Concepts in Spine Care Session: Outcomes Assessment in the New Vernacular of Value," industry experts discussed what "quality" means to these different stakeholders and how physicians can prepare for the future.
Christopher P. Kauffman, MD, began the presentation by discussing why quality measures have been implemented. Healthcare expenditure is highest in the world in the United States. When the World health Organization looked at where the waste was, they found most of U.S. spending was on administrative costs, he said, although government regulations have been increased over the past 10 months with the establishment and implementation of:
• Health Information Technology Act
• American Recovery and Reinvestment Act
• Patient Protection and Affordable Care Act
• EHR legislative requirements
A key proponent of meaningful EHR is intraoperability, but true intraoperability has not yet been achieved with current EHR models.
"So far to date, none of the EHR are interoperable and even if you go from one at the practice to another, they may not talk to each other," said Dr. Kauffman. The stimulus bill put in $19 billion for establishing IT technology for healthcare. This established EHR, increased requirements for reporting quality measures and increased government regulations by requiring surgeons to report back to the government.
The PPACA includes incentives to meet requirements and penalties for providers that don't. Penalties for not ePrescribing and implementing EHR are small individually — 2 percent and 1 percent cumulative on a yearly basis, respectively — but added together will be a significant hit to reimbursement from Medicare. Additionally, penalties are assessed to providers that don't meet PQRS measures beginning in 2014. Dr. Kauffman went over the three components of meaningful use:
• Use of certified EHR in a meaningful manner
• Use of certified EHR technology for electronic exchange of health information to improve quality
• Use of certified EHR technology to submit clinical quality measures and other measures selected by the Secretary of Healthcare
Eligible providers — anyone providing healthcare — must report on specific measures. "As specialists, they are not made for us and they are required by law and mandated by Congress, but it's near impossible for us to accomplish this goal," said Dr. Kauffman. Later he added, "Quality is not clear to them and the incentive for doing this is not clear to patients."
He went over claims-based reporting for quality measures and the new push toward providing "episodes of care" for back pain. There are specific requirements for the patient's pain assessment and functional status assessment. Surgeons are also required to provide specific red flags in the patient's history and assess prior treatment and response back two years.
According to the Centers for Medicare and Medicaid Services, only 30 percent of eligible healthcare providers participated in PQRS in 2011. Physicians not reporting stand to lose up to $1.3 billion in Medicare payments each year, according to the report.
"You can see very quickly that the definition of value is being created by many people in the industry of spine care and we have a role in defining it for ourselves," said moderator Gregory L. Whitcomb, DC.
Donna D. Ohnmeiss spoke on intra- and trans-institutional data pooling and how this information could be used in the future. "One of the important issues is it lets us find complications faster. You can only find a lot of complications if you have a large enough sample of patients because otherwise it might seem like a random happening," she said. "But if you have a large enough sample even a relatively small occurrence will start to show itself. It also lets us increase our ability to identify biases or other sources of variation in outcomes."
Emily Karlen, MPT, then discussed how to begin recording outcomes on a consistent basis and ensuring the data is interpreted meaningfully.
In his second presentation, Dr. Kauffman discussed the difference in how quality is defined between providers, patients and payers — even between Medicare and commercial payers. He posed the question: What are true quality measures?
Commercial providers focus on length of stay and send patient questionnaires about satisfaction — could patients get appointments, see physicians quickly and feel satisfied with the appointment. The private payers are also focusing more on readmissions and implant choices.
CMS has also begun gathering quality data for a website that compares providers. Concerns with the CMS quality programs for physicians include:
• The measures aren't designed for specialists.
• Measures don't lead to better outcomes.
• There is inadequate risk adjustment.
• There are low reporting rates.
• It's difficult to find information about the program.
• Many have a hard time obtaining and interpreting reports.
Some physicians may forego treating Medicare patients to avoid penalties or the administrative burden, but the growing number of people who are covered under government payers will likely increase under the continued implementation of the ACA and could have a trickle-down impact on commercial payers.
"Before you decide not to participate, think about this," said Dr. Kauffman. "Don't just think of CMS, think of the broader picture of where healthcare is going in America. I would encourage you to start somewhere and take the first step…recognize you don't know what you don't know and [the] need to do something."
While it's difficult to define true quality, Dr. Kauffman did encourage spine surgeons to become more vocal advocates for their patients.
"We are our patients' voice and advocate for true quality care," said Dr. Kauffman. "Spine care — we are the only people delivering it so it has to be us who advocate for the quality measures — whatever you feel they are, whether you feel it's going to be through PQRS, registry participation, whether it's going to be pooled data and using that pooled data to show our services are of value to our patients. Quality does not always equal cost savings; don't get bullied into always doing something that is cheaper that is not quality for your patients. Choose a form of participation that you feel is reasonable and potentially meaningful."
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