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CMS’s new carrot-and-stick benchmarking efforts do more to lower costs than raise quality

Rolling in like a Trojan horse, CMS is proclaiming that its new ramped up benchmarking efforts are primarily motivated by efforts to improve quality. In reality, they are really focused on cost-reduction. Will compliance with these programs improve quality? Perhaps. However, for many of the measures, the only certainty is reduced cost and reduced access to tests. Some of the benchmarks measure quality that has already been proven. But some of the benchmarks, if met, may actually result in less quality of care. The consistent theme is less cost, and if quality can be maintained or improved along the way, well that’s nice too.

Some may feel that my view is a bit cynical. However, you’re not paranoid if they really are out to get you! Let’s look at the Physician Quality Reporting System (PQRS), formerly the Physician Quality Reporting Initiative (PQRI). Just for voluntarily reporting on one or more identified “quality measures,” eligible providers could earn a 1.5% bonus (incentive payment). But this was true only if you could figure out how to actually accomplish this. For this reason, very few chose to participate in the first few years. According to the AMA, more than a million providers were eligible in 2009, but only 210,000 participated. And only 120,000 providers actually collected any bonus payments. For all their efforts, those providers shared $234 million, on average less than $2,000 per provider.

Possibly much less than the administrative cost of tracking the quality measure.
So, who cares, if it’s voluntary? There’s no downside, right? Dr. Donald Berwick, former CMS Administrator tipped his hand, however, that this might not always be “voluntary” when he said, “Although participation in our pay-for-reporting programs is optional now, it should be regarded as imperative in terms of medical professionals’ shared goal of improving quality of care and patient safety.”

Indeed, the hay days for making money back for your quality measure benchmarking efforts were 2007 through 2010. After that time, things took an ugly turn. After reaching a high point of a 2% bonus in 2009 and 2010, they fell from 2011 to 2014 and actually became penalties thereafter. (See chart)

Although the administrative cost might be substantial to track and report this data, your chances to recoup those costs are fading fast. As foreshadowed by many, CMS used a “carrot” to get buy-in before engaging the “stick” to reduce cost – I mean improve quality. Here is some more foreshadowing for you. If the bonus becomes a penalty, when do you think “voluntary” reporting will become “mandatory” reporting of quality benchmarks?

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What are the PQRS benchmarks that will apply to emergency medicine?

  • Measure #28: Aspirin at Arrival for Acute Myocardial Infarction (AMI)
  • Measure #31: Stroke and Stroke Rehabilitation: DVT Prophylaxis for Ischemic Stroke or ICH
  • Measure #54: 12 Lead ECG Performed for Non-Traumatic Chest Pain if >40 yo
  • Measure #55: 12 Lead ECG Performed for Syncope if >60 years old
  • Measure #56: Community –Acquired Pneumonia (CAP):Vital Signs
  • Measure #57: Community –Acquired Pneumonia (CAP): Assessment of Oxygen Saturation
  • Measure #58: Community –Acquired Pneumonia (CAP): Assessment of Mental Status
  • Measure #59: Community –Acquired Pneumonia (CAP): Empiric Antibiotic
  • Measure #76: Prevention of Catheter-Related Bloodstream Infections (CRBSI: Central Venous Catheter Insertion Protocol)
  • Measure #91: Acute Otitis Externa (AOE): Topical Therapy
  • Measure #92: Acute Otitis Externa (AOE): Pain Assessment
  • Measure #93: Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use
  • Measure #187: Stroke to stroke rehabilitation: Thrombolytic Therapy
  • Measure #228: Heart Failure (HF): Left Ventricular Function (LVF) testing.


Looking at the list, from a distance it seems that compliance with these should be very easy. However, the devil is in the details. Individual cases requiring adjustments based on clinical judgement get forced into the same mold in an effort to meet the standard of the benchmark.

Here is an example. Measure #55 mandates the performance of an ECG for patients over 60 with syncope. Most would consider this a no-brainer. So why was the currently measured compliance with this measure so poor? In short, the metric is problematic, based on its design. Only one ICD-9 code is used – 780.2. This code applies to all the following: Blackout, Fainting, Near (pre) syncope and Vasovagal attack. Most would agree that in true syncope an ECG is universally indicated in this age group. However, is there consensus that every vasovagal episodes or near syncope requires an ECG? Maybe. But maybe not. It depends on the clinical judgement of the examiner. I doubt that all of us feel that an ECG is indicated in every such case.

The Outpatient and Inpatient Prospective Payment Systems (OPPS and IPPS) that determines what hospitals are paid by CMS will now have a focus on quality reporting of hospital measures. Since many hospital admissions originate in the emergency department, the hospital’s rate of compliance is often impacted by our work. In 2012, hospitals will see a 2% reduction in the annual hospital market basket (basically the fee schedule) if they fail to meet, or refuse to participate in reporting the quality measures mandated by the system.

The 2012 IPPS (inpatient) measures relevant to EM*:

  • AMI-1: ASA at Arrival
  • AMI-8: Median time to PCI
  • AMI-8a: Primary PCI within 90 minutes of hospital arrival
  • PN3a: Blood cultures performed for ICU admissions within 24 hours
  • PN-3b: Blood cultures performed in the ED prior to initial antibiotic received in the hospital
  • PN-5c: Initial antibiotic received within 6 hours of arrival
  • PN-6: Pneumonia patients given the most appropriate initial antibiotics
  • Stroke-4: Tissue Plasminogen Activator (t-PA) considered


*Please note that AMI-1 and PN (pneumonia) 5c have been retired.

For 2012, there are 15 OPPS (outpatient) measures, including imaging efficiency measures. OP-15, for instance, deals with the use of CT for brain imaging for atraumatic headaches, a common complaint in the ED. The measure that CMS employs, however, appears to be methodological flawed. While many charts are eligible for exclusion from the measures, these exclusionary criteria can only be noted by reading the chart. However, CMS only looks at the ICD-9 codes (billing data) when deciding which charts are included in the measure, thus including charts in the benchmarking measure that should be excluded. The National Quality Forum (NQF) twice attempted to have this measure removed. Numerous physicians, this author included, provided critical input during the comment period. However, CMS decided to implement it anyway with the only concession being a delay in the public reporting of this data.

As the Affordable Care Act unfolds and cost containment strategies move from theory to practice, we are likely to see much more pressure to reduce utilization, whether or not there is evidence to support improvements in quality of care. More measures, including ED throughput measures, are on tap for 2013 and 2014. In the coming months, we will bring detailed information to you, regarding these new measures and how they may impact your practice.

Dr. Kevin Klauer is the editor-in-chief of Emergency Physicians Monthly, the CMO of Emergency Medicine Physicians, and the vice speaker of the ACEP Council.


 

 

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