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Patient safety, quality experts hope health reform delivers substantial improvements in care

The health system overhaul will increase quality data reporting, and could help cut hospital readmissions and prevent nosocomial infections.

By Kevin B. O’Reilly — Posted April 19, 2010

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Most of the attention given to the health reform law has focused on its sweeping changes to the insurance system. But the law also could dramatically change the way that care is delivered, according to experts on patient safety and quality.

For example, the overhaul uses pay bonuses and penalties to physicians and hospitals to incentivize the care coordination and safety interventions that can help prevent nosocomial infections and unnecessary hospital readmissions. It also requires an unprecedented level of public reporting on hospital and physician quality performance, and could hasten implementation of care improvement practices, experts said.

The reform law is "a very important step up in a whole variety of initiatives that have been done in this decade in the absence of health care reform," said Bob Wachter, MD. He is chief of medical service at the University of California, San Francisco, Medical Center and editor of AHRQ WebM&M, an online safety journal. "It's looking at how do we promote transparency, how do we use the payment system to motivate providers to focus on quality and safety, and how do we create research and promote collaboratives to understand what we should be doing to improve care."

One element of transparency is public reporting of physician performance data, which is set to start in 2013. Medicare hopes to entice more doctors to take part in its Physician Quality Reporting Initiative with bonuses of 1% next year, dropping to 0.5% through 2014. Starting in 2015, physicians face a 1.5% Medicare pay cut for not participating in PQRI, with a 2% penalty starting in 2016.

The American Medical Association hopes to eliminate scheduled cuts and maintain bonuses. It is working to ensure that any public reporting of physician quality data is accurate.

Meanwhile, a cost-quality value index included in the law will adjust Medicare payments at the individual physician level and takes effect in 2015. In a December 2009 letter to Senate Majority Leader Harry Reid (D, Nev.), American Medical Association Executive Vice President and CEO Michael D. Maves, MD, MBA, said the AMA opposes the idea because it is based on measures that "are not scientifically valid, verifiable, and accurate." AMA President J. James Rohack, MD, said in a March letter that the AMA will "aggressively work for modifications to reflect the realities of medical practice."

The bulk of quality and safety reforms, however, apply to hospitals. The overhaul's carrots-and-sticks approach breaks care into two "buckets," said James Conway, senior fellow at the Institute for Healthcare Improvement in Cambridge, Mass.

"The first bucket is how do you enhance the leading edge? There are a whole bunch of organizations doing good work -- how do you incent them?" Conway said. "The other bucket is how do you raise the floor? If you're by far one of the worst-performing hospitals on Hospital Compare, that's no longer OK."

Hospitals with the highest rates of health care-associated conditions will have their Medicare pay cut 1% starting in October 2014. Medicare's no-pay policy for such conditions will expand to all state Medicaid programs. But hospitals that excel on quality measures can earn a bonus.

"A lot of this is common sense," said Lisa McGiffert, director of the Consumers Union's Safe Patient Project. "If someone hurts you, you don't pay them money for hurting you. If you are having to go to a health system for care, you have a right to know what kind of care that system gives."

Estimates of medical harm vary greatly. The most widely known statistic is in the Institute of Medicine's 1999 report, "To Err is Human," which cited research stating that as many as 98,000 Americans die annually of preventable medical harm. The Centers for Disease Control and Prevention estimates that 99,000 people die annually of hospital infections, though it is unclear how many of those could be prevented.

Concerning quality of care, an influential 2003 study of 13,000 adults in 12 metropolitan areas conducted by the RAND Corp. found that patients received only 55% of guideline-recommended care. A report released in April by the Agency for Healthcare Research and Quality found that the U.S. health system improved on 51% of patient safety measures and 63% of quality measures in 2009.

Addressing readmissions

A major quality target of health reform is hospital readmissions.

Studies have found that about 20% of Medicare patients are readmitted to the hospital within 30 days of discharge. Hospitals with high readmission rates will have their payments cut. The change will save Medicare $7 billion over 10 years, the Congressional Budget Office estimates.

The change will push hospitals to do a better job of discharge planning and work more closely with community physicians, nursing homes, assisted-living facilities and home health agencies, said Harlan M. Krumholz, MD, director of the Yale-New Haven Hospital Center for Outcomes Research and Evaluation.

"There will be a lot of attention on this high-risk period of transition from being an inpatient to being an outpatient -- a period of time that's really fallen through the cracks," said Dr. Krumholz, whose team at Yale helped develop the readmissions measures Medicare uses for public reporting in Hospital Compare. "This at least gives [hospitals] a financial reason to invest in this."

Yet not all readmissions are preventable, and many are outside the control of hospitals, said Nancy Foster, vice president for quality and patient safety policy at the American Hospital Assn. She said the readmissions provision could hurt patients.

"The thing I worry about most is the potential to add further stress in the emergency room," Foster said. "The patient may come back to the ER not feeling very well, and there may be a lot of pressure on the ER physician to, if they can possibly, send the patient back home because the hospital doesn't want to be financially in jeopardy because of a readmission."

The IHI's Conway said the reform law only begins the work needed to improve health care quality and safety. "The action now is in the execution," he said.

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ADDITIONAL INFORMATION

Safety, quality measures in health reform

The health reform overhaul employs various mechanisms to improve quality and patient safety. Among them:

  • Doctors who participate in Medicare's Physician Quality Reporting Initiative will get a bonus of 1% in 2011 and 0.5% from 2012 to 2014. An extra 0.5% bonus is available to doctors who participate in their specialty board's maintenance-of-certification program. Starting in 2015, doctors who do not take part in PQRI will have their Medicare payments reduced 1.5%. The penalty will be 2% beginning in 2016.
  • Public reporting of physician performance data starts in 2013.
  • Hospitals with high readmission rates for patients with conditions such as heart failure will have their payments cut. The change takes effect in October 2012, with the conditions list expanded in 2014.
  • The Dept. of Health and Human Services will start tracking hospital-acquired conditions such as pressure ulcers and in October 2014 will reduce Medicare payments by 1% for hospitals whose harm rates are in the top quartile. The Congressional Budget Office says the change will save $1.4 billion over 10 years.
  • Medicare's no-pay policy for health care-associated conditions will be expanded to all state Medicaid programs. Starting in 2014, hospitals' record of cases for which payment was denied will be reported publicly.
  • Hospitals that meet performance standards set by HHS on at least five quality measures will get a pay bonus from a pool of funds collected from all hospitals, starting in October 2012.
  • A cost-quality index modifier set to take effect in 2015 will redistribute Medicare payments to physicians based on risk-adjusted measurements of quality and health care outcomes.
  • A Center for Medicare and Medicaid Innovation will experiment with different care payment mechanisms to tackle priorities such as reducing readmissions and improving chronic care management.
  • The Center for Quality Improvement and Patient Safety will fund research into problems such as hospital infections, readmissions and intensive care, disseminating its findings to physicians, hospitals and the public.

Sources: American Medical Association; Consumers Union; House Energy and Commerce Committee; Senate Democratic Policy Committee

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