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25 posts from August 2012

August 31, 2012

National Quality Forum Endorses 12 Measures on Access to Coordinated Care

Medical team
Continuing its trend of releasing new measures, the National Quality Forum (NQF) Board of Directors recently endorsed 12 measures that assess coordination of care – an essential ingredient in efforts to improve care quality and safety.   The measures touch on such critical areas of concern as reconciling patients’ medications, establishing advance care plans, and the timely availability of medical records (to other caregivers and patients themselves) when patients are discharged from hospitals and other in-patient facilities.           

“Care coordination is essential to reducing medical errors, wasteful spending, and unnecessary pain and procedures for patients,” said Laura J. Miller, FACHE, interim CEO of NQF.  “We are pleased to endorse this set of measures that will help providers deliver safer, coordinated, and higher-quality care to patients.”  

Lack of coordination and communication across healthcare settings can lead to significant patient complications, including medication errors, preventable hospital readmissions, and emergency department visits. The Institute of Medicine (IOM) has estimated that care coordination initiatives addressing such complications could result in $240 billion in healthcare savings. 

“These measures are an important part of the NQF portfolio,” said Gerri Lamb, PhD, RN, FAAN, associate professor, Arizona State University College of Nursing and Health Innovation, and co-chair of the Care Coordination Steering Committee.  “As the number of older adults with multiple chronic conditions in the United States continues to grow, their treatment needs are often complex and varied. Care coordination measures will help the healthcare community work together to provide more efficient, effective, and high-quality care.” 

The measures include those that have been endorsed for at least three years and are now undergoing NQF endorsement maintenance. T he ongoing evaluation and updating of endorsed measures ensures they are current and relevant to NQF’s care coordination portfolio.  In all, 15 measures were evaluated against NQF’s endorsement criteria, with 12 receiving endorsement status.   

The Committee identified measurement gaps in care coordination with a focused assessment of the role of health information technology in moving toward the next generation of measures. “Even though we currently lack comprehensive quality measurements of effective care coordination , these endorsed measures help set the stage for the future,” said Donald Casey Jr., MD, MPH, MBA, former chief medical officer and vice president of quality for Atlantic Health and co-chair of the Care Coordination Steering Committee.  

 “Ultimately we want to see measure developers align their efforts with NQF’s Preferred Practices for Care Coordination. The domains of these practices include the healthcare home, developing and implementing a proactive and patient-centered plan of care, effective communication between patients, families and caregivers, efficient information systems that support timely communication, and transitions of care that promote safe, evidence-based care."   

NQF is a voluntary consensus standards-setting organization.  Any party may request reconsideration of any of the 12 endorsed quality measures listed below by submitting an appeal no later than September 10 (to submit an appeal, go to the NQF Measure Database).  For an appeal to be considered, the notification must include information clearly demonstrating that the appellant has interests directly and materially affected by the NQF-endorsed recommendations and that the NQF decision has had (or will have) an adverse effect on those interests.

August 30, 2012

ACCME July 2012 Board of Directors Meeting Summary

Board meeting
The Accreditation Council for Continuing Medical Education (ACCME) recently released its August 2012 newsletter.  The newsletter addresses a number of important topics for continuing medical education (CME) providers and stakeholders including, but not limited to: 

  • A summary of the ACCME Board of Directors July 2012 Meeting;
  • Simplified requirements for communicating information in Internet CME activities and Enduring Materials; and
  • The Food and Drug Administration’s (FDA) issuance of a final Risk Evaluation and Mitigation Strategy (REMS) for Extended-Release/Long-Acting Opioid Analgesics 

July 2012 ACCME Board of Directors Meeting 

Held July 26-27, the Board ratified 61 accreditation and reaccreditation decisions, including 20 providers (33%) that received Accreditation with Commendation, which confers a 6-year term of accreditation—this included the Potomac Center for Medical Education (PCME).   As of July 2012, there are 702 ACCME-accredited providers and 1,338 providers accredited by ACCME Recognized Accreditors (state or territory medical societies that accredit local organizations offering CME).  In addition: 

  • Twenty-three (38%) received Accreditation; 18 of these providers (30%) are required to submit progress reports; 5 (8%) do not need to submit progress reports.
  • Nine providers (15%) were placed on Probation and are required to submit progress reports.
  • All of the 9 initial applicants received Provisional Accreditation (15% of the total; 100% of initial applicants). 

The Board ratified 28 progress report decisions.  Of those, 23 (82%) progress reports demonstrated compliance with all ACCME requirements previously found not in compliance, and were accepted.  Four progress reports (14%) failed to demonstrate compliance in all requirements and the providers are required to submit another progress report. One progress report decision (4%) was deferred. 

For those who criticize CME providers, particularly those that accept commercial support, this summary should provide sufficient evidence that the ACCME not only has appropriate firewalls to protect against undue influence or bias, but that the ACCME also engages in significant oversight of providers and enforces its rules and regulations, including its Standards for Commercial Support (SCS).  With 15% of providers being placed on probation and another 30% being required to submit progress reports, it is clear that the ACCME takes compliance very seriously.   

The Board also convened conversations with leadership from the recognized state/territory medical society CME accreditation system to discuss the evolution, standards, expectations, obligations, challenges, and opportunities facing accredited CME.  The Board asked participants about the value their accreditation program brings to their state, about the value of ACCME support and services, and how the ACCME can continue to support their accreditation programs.   

Participants included ACCME member organization liaisons; members of the Committee for Review and Recognition (CRR); and CEOs, executive leadership, and staff from 38 recognized state/territory medical societies. The conversations were part of the Board’s ongoing process for facilitating the implementation of the ACCME 2011 strategic imperatives: Foster ACCME Leadership and Engagement; Evolve and Simplify the Accreditation Standards, Process, and System; Explore and Build a More Diversified Portfolio of ACCME Products and Services. 

Internet-based CME and Enduring Materials: Modifying Communication Requirements  

In response to questions from accredited providers and technological advancements, the Board re-examined its requirements regarding the communication of information to learners as described in the Internet CME and Enduring Materials policies.  The Board agreed to simplify its interpretation of the requirements because of the evolution of technology and learners' increasing familiarity with technology.   

The Internet CME and Enduring Materials policies require providers to communicate to learners information such as the activity’s principal faculty and their credentials, estimated time to complete the activity, hardware/software requirements, the providers' privacy and confidentiality policy, and other information. The policies state that this information must be communicated to learners prior to the activity.  Previously, the ACCME has interpreted “prior to the activity” to mean that learners must be made to pass through the information.  The ACCME did not consider it acceptable for providers to use optional links in electronic CME activities that allowed learners to go directly to the CME content and bypass the information required by the Internet CME and Enduring Materials policies. 

ACCME will now be acceptable, in effect immediately, for providers to choose from various electronic means, such as tabs, links, “click here” buttons or rollover text, or other electronic means to make the required information accessible.  The Board recognized that the use of tabs or links to disseminate information is now the online standard.   

For CME activities in which the learner participates electronically (e.g., via the Internet), all required information specified in the ACCME’s Enduring Materials: Definition and Requirements Policy and the Internet CME Policy must be made accessible to the learner prior to the learner beginning the CME activity.  

This modification does not apply to disclosure information required in the Standards for Commercial Support 6: Disclosures Relevant to Potential Commercial Bias to the learner prior to the beginning of the CME activity.  Learners must be made to pass through the information in order to engage in the CME activity.  The use of tabs, links, or other electronic means that allow learners to go directly to the CME content and bypass the information are not acceptable methods for complying with Standard for Commercial Support 6.  The ACCME has provided Q&A to explain the modified requirements.  

ACCME’s Decision-Making Process: Ensuring Consistency and Accuracy

The Board heard a report from the Quality Improvement Committee about an audit of the ACCME's decision-making process for the July 2012 cohort, which included an analysis of the internal controls the ACCME employs to ensure the consistency and accuracy of decision-making.  The Board agreed that the ACCME’s internal controls are effective in supporting valid and consistent accreditation decisions.  The Board will continue to monitor and improve, where necessary, its internal controls.  This most recent audit builds on the work of the Board of Directors 2010 Monitoring Task Force which spent a year reviewing and analyzing the ACCME’s internal controls and determined that the process for ensuring the consistency and fairness of accreditation decision-making should continue to be a high priority. 

ACCME 2012 Bylaws  

In accordance with ACCME bylaws, the revised bylaws became effective July 22, 2012. The ACCME updated its documents and policies to support implementation of the 2012 bylaws. 

FDA Releases REMS for Extended-Release/Long-Acting Opioids 

As we reported back in July, FDA released its REMS for extended-release and long-acting (ER/LA) opioid analgesics.  The centerpiece of the ER/LA Opioid Analgesic REMS is a prescriber education program about the risks of opioid medications as well as safe prescribing and safe use practices.  The FDA developed and issued a blueprint, which contains the core educational messages. The education will be controlled, designed, and delivered by accredited continuing health care education providers, based on the blueprint.  The first page of the blueprint says that “accrediting bodies and CE providers will ensure that the CE activities developed under this REMS will be in compliance with the standards of the ACCME or another CE accrediting body.” 

The education will be funded by a consortium of opioid manufacturers, the REMS Program Companies (RPC), through educational grants to accredited CE providers, so that it is available free of charge or at nominal cost to prescribers.  “We appreciate that the FDA recognizes the value of accredited education and chose to leverage the CE system to carry out this important public health initiative,” said Murray Kopelow, MD, ACCME President and CEO, in an audio commentary.  “Accredited CME providers can base their activities on the blueprint and be in compliance with the ACCME Standards for Commercial Support.” 

ACCME Participates in AMA, ABMS, AAMC Meetings 

The ACCME participated in several meetings during the past few months as part of its ongoing collaboration with member organizations. Through joint leadership initiatives, the ACCME and member organizations identify and implement strategies for improving physicians' continuing professional development and patient care.  For example, the ACCME participated in a meeting of the Coalition for Physician Accountability held in August in Philadelphia.  They also participated in a meeting hosted by the Educational Commission for Foreign Medical Graduates. The Coalition comprises national organizations responsible for physician assessment, accreditation, licensure, and credentialing.  

August 29, 2012

CMS Begins Penalizing Hospitals for Readmissions

Readmissions 2
Section 3025 of the Affordable Care Act (ACA) added section 1886(q) to the Social Security Act establishing the Hospital Readmissions Reduction Program, which requires the Centers for Medicare & Medicaid Services (CMS) to reduce payments to Inpatient Prospective Payment System (IPPS) hospitals with excess readmissions, effective for discharges beginning on October 1, 2012.   

CMS defined readmission as an admission to a subsection (d) hospital within 30 days of a discharge from the same or another subsection (d) hospital.   

“Almost one in five Medicare beneficiaries that leave a hospital end up being readmitted within 30 days,” said Janet Corrigan, PhD, MBA, president and CEO of NQF. “Those readmissions cost about $15 billion annually, and many have the potential to be prevented. These new measures help push us as a nation to address this serious problem.”  

Consequently, Kaiser Health News recently reported that starting in October, more than 2,000 hospitals — including some nationally recognized ones — will be penalized by CMS because many of their patients are readmitted soon after discharge.  “Together, these hospitals will forfeit about $280 million in Medicare funds over the next year as the government begins a wide-ranging push to start paying health care providers based on the quality of care they provide.” 

The significant penalties levied on hospitals underscore the need for more hospitals and health care providers to receive continuing medical education (CME) to improve their patient outcomes and reduce readmissions.  


In the FY 2012 IPPS final rule, CMS finalized the readmission measures for Acute Myocardial Infarction, (AMI) Heart Failure (HF) and Pneumonia (PN) and the calculation of the excess readmission ratio, which will then be used, in part, to calculate the readmission payment adjustment under the Hospital Readmissions Reduction Program.   

CMS finalized the calculation of a hospital’s excess readmission ratio for AMI, HF and PN, which is a measure of a hospital’s readmission performance compared to the national average for the hospital’s set of patients with that applicable condition.  As an example, if a hospital received the maximum penalty of 1 percent and it submitted a claim for $20,000 for a stay, Medicare would reimburse it $19,800. 

CMS established a policy of using the risk adjustment methodology endorsed by the National Quality Forum (NQF) for the readmissions measures for AMI, HF and PN to calculate the excess readmission ratios.  CMS did not take into account patients’ racial or socio-economic background. 

The excess readmission ratio includes adjustment for factors that are clinically relevant including patient demographic characteristics, comorbidities, and patient frailty.  Finally, CMS established a policy of using three years of discharge data and a minimum of 25 cases to calculate a hospital’s excess readmission ratio of each applicable condition.  For FY 2013, the excess readmission ratio is based on discharges occurring during the 3-year period of July 1, 2008 to June 30, 2011. 

Hospital Penalties 

The penalties will fall heaviest on hospitals in New Jersey, New York, the District of Columbia, Arkansas, Kentucky, Mississippi, Illinois and Massachusetts, a Kaiser Health News analysis of the records shows.  Hospitals that treat the most low-income patients will be hit particularly hard. 

A total of 278 hospitals nationally will lose the maximum amount allowed under the health care law: 1 percent of their base Medicare reimbursements. Several of those are top-ranked institutions, including Hackensack University Medical Center in New Jersey, North Shore University Hospital in Manhasset, N.Y. and Beth Israel Deaconess Medical Center in Boston, a teaching hospital of Harvard Medical School.  

According to Medicare records, 1,933 hospitals will receive penalties less than 1 percent; the total number of hospitals receiving penalties is 2,211. Massachusetts General Hospital in Boston, which U.S. News last month ranked as the best hospital in the country, will lose 0.5 percent of its Medicare payments because of its readmission rates, the records show.  The smallest penalties are one hundredth of a percent, which 50 hospitals will receive. 

Gundersen Lutheran Health System in La Crosse, Wis., and Intermountain Medical Center in Murray, Utah, were among 1,156 hospitals where Medicare determined the readmission rates were acceptable. Those hospitals will not lose any money.  On average, the readmissions penalties were lightest on hospitals in Utah, South Dakota, Vermont, Wyoming and New Mexico, the analysis shows. Idaho was the only state where Medicare did not penalize any hospital.  

One of the problems with readmissions is that “hospitals have had little financial incentive to ensure patients get the care they need once they leave, and in fact they benefit financially when patients don’t recover and return for more treatment.”

Nearly 2 million Medicare beneficiaries are readmitted within 30 days of release each year, costing Medicare $17.5 billion in additional hospital bills.  CMS noted that readmissions alone cost $26 billion in a decade. The national average readmission rate has remained steady at slightly above 19 percent for several years, even as many hospitals have worked harder to lower theirs.   

CMS has been trying to help hospitals and community organizations by giving grants to help them coordinate patients’ care after they’re discharged.  Leaders at many hospitals say they are devoting increased attention to readmissions in concert with other changes created by the health law. 

Hospitals That Serve Poor Are Hit Harder than Others 

The penalties have been intensely debated.  Studies have found that African-Americans are more likely to be readmitted than other patients, leading some experts to be concerned that hospitals that treat many blacks will end up being unfairly punished. 

Some safety-net hospitals that treat large numbers of low-income patients tend to have higher readmission rates, which the hospitals attribute to the lack of access to doctors and medication these patients often experience after discharge.  

Kaiser’s analysis of the penalties shows that 76 percent of the hospitals that have a lot of low-income patients will lose Medicare funds in the fiscal year starting in October. Only 55 percent of the hospitals treating few poor patients are going to be penalized, the analysis shows.  The hospital industry has emphasized that poor patients are more likely to be readmitted, as they have a tougher time affording medications, often don’t have access to doctors for check-ups and can have difficulty securing transportation to get follow-up care.  Hospitals also have complained that many safety-net hospitals operate on tight margins. 

One hundred hospitals in the group with the most poor patients –12 percent – will receive the maximum penalty from CMS: a 1 percent decrease in their reimbursements starting in October. By contrast, only 47 hospitals, or 6 percent, in the group with the fewest poor patients will receive the maximum penalty, the data show.  Dr. John Lynch, chief medical officer at Barnes-Jewish Hospital in St. Louis, which is receiving the maximum penalty, noted that “Some of the hospitals that are going to pay penalties are not going to be able to afford these types of interventions,” who estimated the penalty would cost Barnes-Jewish $1 million. 

Kaiser’s analysis of the data show that 204 safety net hospitals overcame their patients’ challenges to minimize readmissions to a level that Medicare determined did not warrant any penalty. Among the hospitals with the fewest low-income patients, 379 avoided any penalty.  

Atul Grover, chief public policy officer for the Association of American Medical Colleges, called Medicare’s new penalties “a total disregard for underserved patients and the hospitals that care for them.”  Blair Childs, an executive at the Premier healthcare alliance of hospitals, said: “It’s really ironic that you penalize the hospitals that need the funds to manage a particularly difficult population.” 

Medicare disagreed, writing that “many safety-net providers and teaching hospitals do as well or better on the measures than hospitals without substantial numbers of patients of low socioeconomic status.”  Safety-net hospitals that are not being penalized include the University of Mississippi Medical Center in Jackson and Denver Health Medical Center in Colorado.  “We do not want to hold hospitals to different standards for the outcomes of their patients of low socioeconomic status,” CMS wrote in a regulation issued earlier this month.  The agency added:”"We do not want to mask potential disparities or minimize incentives to improve the outcomes of disadvantaged populations.” 

However, there are a number of aspects at Denver Health that are hard to replicate everywhere. Denver Health, Colorado’s biggest safety net system, includes a 477-bed hospital and eight community primary care clinics.  About a third of its patients are uninsured, another third are on Medicaid. The integrated system and low reimbursement rates create both a financial incentive and an opportunity to provide as much care as possible in the lower cost outpatient settings. 

“We also are a hospital that is often at full capacity,” Dr. Thomas MacKenzie of Denver Health says, “so we certainly have an incentive when we’re busting at the seams…to make sure patients aren’t readmitted unnecessarily.”  Denver Health was also an early adopter of electronic medical records. MacKenzie says easy sharing of patient information between the hospital and clinics effectively keeps admissions down. It also helps those recently discharged get priority in scheduling follow-up appointments, putting them at the head of what can be long wait lists at community clinics. 

But experts say some hospitalizations are simply unavoidable.  “My view is that in the current state of the American health-care system, a 30-day readmission is not a hospital metric, a 30-day readmission rate is a health system metric,” said Dr. P.J. Brennan.

Brennan, the chief medical officer for the University of Pennsylvania Health System, said hospitals are trying to keep their arms around patients after discharge, but a patient’s personal finances, health literacy and access to primary care are beyond the control of any individual institution. 

“No patient should be readmitted within seven days. Seven days is something that every hospital ought to be able to take care of,” Brennan said. “At some point, other factors begin to impact.” 

Moving Forward 

The maximum penalty for readmissions will increase after this year, to 2 percent of regular payments starting in October 2013 and then to 3 percent the following year. This year, the $280 million in penalties comprise about 0.3 percent of the total amount hospitals are paid by Medicare.  CMS will also soon penalize or reward hospitals based on how well they adhere to basic standards of care and how patients rated their experiences.  Overall, Medicare has decided to penalize around two-thirds of the hospitals whose readmission rates it evaluated. 

The implementation of penalties for hospital readmissions underscores the need for additional training and education of healthcare providers at hospitals.  Continuing medical education (CME) can address many of these issues and help healthcare providers attain their goals in ensuring patients with the measured conditions are not readmitted. 



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