Policy and Medicine

CMS: 2014 Clinical Quality Measures

The Centers for Medicare & Medicaid Services recently released the final 2014 clinical quality measures (CQMs) for eligible professionals and eligible hospitals, and the specifications for electronic reporting. 

Beginning in 2014, providers will need to report the new CQMs whether they are reporting in Stage 1 or Stage 2 of the Meaningful Use program.  Eligible professionals will report on nine of 64 CQMs; eligible hospitals will report on 16 of 29 hospitals.

When selecting the CQMs to report, providers must select ones that cover at least three of six domains that have been identified as U.S. Department of Health & Human Services National Quality Strategy priorities for healthcare quality improvement, according to CMS’ tip sheet.  The domains are: 

• Patient and Family Engagement
• Patient Safety
• Care Coordination
• Population and Public Health
• Efficient Use of Healthcare Resources
• Clinical Processes/Effectiveness 

CQMs were a core meaningful use objective in Stage 1 of the program.  They no longer are a core Meaningful Use objective, but providers are still required to submit CQMs in order to successfully participate in the program, according to CMS. 

Attestation also will change, going by the wayside. Beginning in 2014, providers beyond their first year of Meaningful Use must report CQM data electronically.  CMS also has posted the specifications for this reporting on its website. 

CMS is providing new resources to help providers with these changes, including a Data Element Catalog, a Value Set Authority Center, and a United States Health Information Knowledgebase, according to the Office of the National Coordinator for Health IT.

The final rule, published in the Federal Register on Sept. 4, contained several errors concerning the CQMs. The agency issued a document in October to correct these and other errors.   

2013  

Eligible Professionals (EPs), will continue to report from the 44 measures finalized for Stage 1 in the same schema laid out for Stage 1 3 core/alternate core  3 additional measures for EPs  

• Eligible hospitals and CAHs will continue to report the 15 measures finalized for Stage 1
• Beginning in 2012 and continuing in 2013, there are two reporting methods available for reporting the Stage 1 measures: Attestation (https://ehrincentives.cms.gov/)
• eReporting Pilots: Physician Quality Reporting System EHR Incentive Program Pilot for EPs
• eReporting Pilot for eligible hospitals and CAH  

2014 and Beyond  

EPs must report on 9 of the 64 approved CQMs Recommended core CQMs – encouraged but not required 9 CQMs for the adult population  

• 9 CQMs for the pediatric population
• NQF 0018 strongly encouraged since controlling blood pressure is high priority goal in many national health initiatives, including the Million Hearts campaign  

Selected CQMs must cover at least 3 of the National Quality Strategy domains (See “Measure Selection Process” below.)  

Eligible Hospitals and CAHs must report on 16 of the 29 approved CQMs Selected CQMs must cover at least 3 of the National Quality Strategy domains (See “Measure Selection Process” below.)  

Beginning in 2014, all Medicare-eligible providers beyond their first year of demonstrating meaningful use must electronically report their CQM data to CMS. (Medicaid EPs and hospitals that are eligible only for the Medicaid EHR Incentive Program will electronically report their CQM data to their state.)

Joint Commission Issues New Criteria for Medical Education and Clinical Research

Joint Commission-accredited academic medical centers (AMCs) will see new criteria for medical education and clinical research incorporated into the evaluation process.  The new standards for AMCs were issued on July 1, 2012 and will be effective for all eligible organizations on January 1, 2013.  

An independent, not-for-profit organization, The Joint Commission accredits and certifies more than 19,000 health care organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards. 

“These standards were also developed to present a framework for including medical education and human subject research into the quality and patient safety activities of academic medical center hospitals,” Paul vanOstenberg, JCI's vice president of International Accreditation, Standards and Measurement, said today in a statement.   “These standards were also developed to present a framework for including medical education and human subject research into the quality and patient safety activities of academic medical center hospitals.  Unless deliberately included in the quality framework, education and research activities often are the unnoticed partners in patient care quality monitoring and improvement.” 

To meet the eligibility criteria, hospitals must be organizationally or administratively integrated with a medical school, serve as the principal site for the education of both medical students and medical specialty residents from the integrated medical school, and conduct academic and/or commercial human subject research involving patients of the hospital. 

Meanwhile, those considered AMCs must make sure to carefully explore mergers, acquisitions and affiliations to survive in the consolidating healthcare environment, advised Healthcare Strategies & Solutions, noted Becker's Hospital Review. 

To achieve clinical growth and fulfill their academic mission, academic medical centers need to take a proactive approach to finding the most suitable partner.  A March report from consulting firm PricewaterhouseCoopers (PwC) recommended academic medical centers team up with high-quality, low-cost providers like community hospitals. 

The new standards applicable to academic medical centers are divided into two chapters – Medical Professional Education (MPE) and Human Subject Research Programs (HRP) – as medical education and clinical research are most frequently organized and administered separately within academic medical centers. For all hospitals meeting the eligibility criteria, these two chapters will be a required addition to the Joint Commission International Accreditation Standards for Hospitals, 4th Edition.  

These new standards will be integrated into the evaluation process for the accreditation of hospitals. For example, when the on-site evaluators are reviewing patient care in a clinical unit, they will also evaluate the contribution of medical trainees to care processes in that unit, and the integration of clinical research protocols into the care provided on the unit and the quality monitoring processes. 

Not every hospital with students or conducting research is considered an academic medical center hospital under these new standards, according to vanOstenberg. JCI will evaluate hospitals under the academic medical center hospitals requirements when the hospital:  

• Is organizationally or administratively integrated with a medical school;
• Is the principal site for the education of both medical students and medical specialty residents from the medical school noted in the previous criterion; and
• Conducts academic and/or commercial human subject research involving patients of the hospital.

National Quality Forum Endorses 12 Measures on Access to Coordinated Care

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.

National Quality Forum Announces Patient Safety Measures

Medical errors and unsafe care kill tens of thousands of Americans each year.  For example, an estimated two million healthcare-associated infections occur each year in the United States, accounting for approximately 90,000 deaths.

Consequently, the National Quality Forum (NQF) recently endorsed 14 patient safety measures focused on reducing complications such as medication errors, wrong-site surgery and patient burns, the nonprofit organization announced.

NQF reviewed 27 measures and endorsed 14 of them for at least three years, with ongoing evaluation and updating.  It left three patient-safety measures under consideration.

“Improving patient safety is a cornerstone of NQF’s mission to advance healthcare quality,” said Janet Corrigan, PhD, MBA, president and CEO of NQF. “We are proud to endorse this set of measures that will be vital in helping providers protect patients from harm and deliver safer, high-quality care.”

“Preventable errors in healthcare are costing Americans in a number of ways, whether in premiums, lost work time and wages or undue stress and anxiety for patients and families,” Detroit's Henry Ford Health System Senior Vice President and Chief Quality Officer William A. Conway said in a statement.  “This measure set will ensure the healthcare community has the right measurement tools to help alleviate these burdens and provide patients with high-quality care.”

The measures include only those that have been endorsed for at least three years and are now undergoing NQF endorsement maintenance.  The ongoing evaluation and updating of endorsed measures ensures they are current and relevant to NQF’s patient safety portfolio.

“These measures are an important part of the NQF measure portfolio,” said Pamela Cipriano, PhD, RN, senior director at Galloway Consulting and co-chair of the Patient Safety Measures steering committee.  “They help providers examine adverse events and increase accountability to implement improvements that will protect patients and enable the safe, high-quality, and compassionate care they deserve.”

To keep patients safe from medical complications, hospitals can launch programs that improve physician-nurse communication and teamwork to reduce surgery-related blood clots and infections or achieve physician buy-in for checklists and standardized procedures to prevent wrong-site surgeries.

Patient safety has been in the news a lot lately, with hospitals getting--and disputing--new safety report cards from the Leapfrog Group earlier this month.

Back in April, the NQF endorsed two new measures for all-cause unplanned readmissions, despite provider criticism of using national measures of readmissions as a quality indicator.  NQF said those measures account for multiple factors that affect readmissions, including the complexity of the medical condition, effectiveness of inpatient treatment and care transitions, patient adherence to treatment plans and patient health literacy, FierceHealthcare previously reported.

Getting from Volume to Value in Healthcare

Forbes Insights recently released “Getting From Volume to Value in Health Care: Balancing Challenges & Opportunities,” a study examining health care professionals’ opinions about value-based purchasing (VBP).  At its most basic, value-based purchasing (VBP) asserts that buyers should hold providers of health care accountable for both cost and quality of care.

As one widely used definition puts it: “Value-based purchasing brings together information on the quality of health care, including patient outcomes and health status, with data on the dollar outlays going towards health. It focuses on managing the use of the health care system to reduce inappropriate care and to identify and reward the best-performing providers.”

Medicare’s Value-Based Purchasing program under the Affordable Care Act (ACA) goes into effect on Oct. 1, 2012, the start of the government’s FY 2013.  Under the program Medicare will withhold a small part of hospital reimbursement each year and then redistribute it as incentive payments based on specific groups of quality measures.

VBP is now widely seen as a replacement for traditional fee-for-service reimbursement.  A crucial unanswered question is how quickly VBP will go from accepted concept to actual contracts.  Allscripts Healthcare Solutions, Inc. sponsored the study.

The responses of more than 200 hospital and health system senior executives in the survey reflect the balancing act that's necessary to get their organizations from the-way-things-have-always-been to the-way-things-will-be without tumbling into a financial chasm because of the-way-things-are now.  The executives’ concerns focused on three broad areas: the speed, scope and synchronization of VBP-related change.

“Physicians have been paid on a fee-for-service basis since Hippocrates made his first house call,” said Michael L. Millenson, president of Health Quality Advisors LLC and the author of the report. “Value-based purchasing represents a true paradigm shift to paying for value instead of volume.”  Key findings of the study included:

• An Imminent Shift: Almost three-quarters (73%) of the C-suite executives surveyed completely or somewhat agreed that providers must immediately begin shifting their focus from volume to value.
• Disruptive Potential of Value-Based Purchasing: Nearly four in ten respondents (38%) completely or somewhat agreed that VBP is likely to become a truly disruptive innovation.
• Crucial to Win Hearts and Minds: Fully engaging their doctors was seen by surveyed C-suite executives as the top barrier to VBP participation, selected by half of respondents.
• A Warning on Consumer-Driven Health Plans: About two-thirds of surveyed executives believed that consumer financial incentives are key to making VBP successful (64%). However, about the same percentage (67%) also thought that consumers won't know when that success arrives, since they can't judge the value of medical care accurately. That's a flashing warning sign for those who believe that the high-deductible health insurance arrangements known as consumer-driven health plans will automatically drive value-based purchasing on the part of the patient.
• VBP Will Require Seamless Communications: Nearly half of respondents chose system integration across all applications (49%) and health information exchange (47%) among their top IT spending priorities for VBP over the next three years.
• The Critical Role Played by Health IT in Both Financial and Clinical Preparedness: This can be seen by what C-suite executives single out as its most important uses, such as identifying patients who generate high costs within the hospital (66%) and in the ambulatory environment (56%); ensuring evidence-based protocols are available to nurses and doctors (61%); and getting complete and current information across the care continuum (58%).
• Vital to Manage Chronic Disease: Asked to choose which three clinical, financial or patient engagement challenges are most important for a successful VBP transition, hospital executives most often picked “effective use of intervention strategies for chronic disease patients” (60%).  Almost as many (55%) chose “improve patient education and engagement.”
• Executives also said that challenges to VBP include reducing preventable readmissions (49%); improving patient/family experience and satisfaction (47%); and improving transitions of care through better coordination (45%)

Despite the challenges, executives interviewed in greater depth shared a common optimism.  As Dr. Robert Margolis, CEO and managing partner of Torrance, Calif.-based HealthCare Partners, put it: “You manage by having a strong vision people believe in, mission and values, and lots of communication.”

“We are committed to helping our clients through this change, which is why we sponsored this survey,” said Glen Tullman, Chief Executive Officer of Allscripts. “The results make it clear that the industry sees some hurdles to making value-based purchasing work. We're continuing to develop tools and solutions to help our clients make the shift successfully.”

Somewhat surprisingly, 63% of those surveyed are either participating in a Medicare ACO already or expect to do so eventually—though it’s unclear how long it will be before those “expectant” ACOers give birth to a fully formed risk-bearing entity. The majority of survey respondents also said they’d been approached by private payers and/or state and local payers regarding VBP.

National Quality Forum: New Quality Measures

The National Quality Forum (NQF) has been releasing a number of new quality measures over the past few months.  In a recent announcement, NQF endorsed a measurement framework for individuals with multiple chronic conditions.  “Performance measurement is critical to improving the health and well-being of individuals with multiple chronic conditions,” NQF President and CEO Janet Corrigan said in a recent statement. 

Making up one-quarter of the population, multiple chronic condition patients are more likely to have adverse outcomes, see multiple clinicians, take several medications and receive fragmented care. As the population continues to age, that percentage is expected to grow. This population is at significantly higher risk of adverse outcomes and complications, and is more likely to see multiple clinicians, take several medications, and receive fragmented, incomplete, and ineffective care. Yet despite wide recognition of this problem from the healthcare community, existing quality measures largely do not address multiple chronic conditions. 

As a result, NQF convened a multi-stakeholder Steering Committee to develop this measurement framework under contract with the Department of Health and Human Services.  Specifically, the framework: 

• Establishes a definition for multiple chronic conditions in order to achieve a common understanding and a shared vision for effectively measuring the quality of care for affected individuals;
• Identifies high-leverage measurement areas for the multiple chronic conditions population in an effort to mitigate unintended consequences and measurement burden;
• Presents a conceptual model that serves as an organizing structure for identifying and prioritizing quality measures; and
• Offers guiding principles to address methodological and practical measurement issues.  

The standards-setting organization this month also released nine surgical measures performed in hospitals and in outpatient facilities, 19 quality measures for preventative care on population health and two nursing home measures that expand the setting to include inpatient rehabilitation facilities and long-term acute care hospitals. Statement 

“As the healthcare community looks to implement new care delivery models, we must consider how individuals with multiple chronic conditions will be affected,” said Caroline Blaum, co-chair of the Multiple Chronic Conditions Steering Committee. “This framework outlines a potential path for new models that thoughtfully takes into account the needs of this population.” In addition, the report identifies several timely strategic opportunities for applying the framework that are relevant to current policy context. These include: 

• A coordinated approach for filling measure gaps;
• Building a common data platform to consistently and seamlessly collect information, including patient reported data;
• Opportunities to apply the core tenets of the framework as new delivery models are implemented and tested; and
• Transparency through public reporting to enable consumer decision-making.  

“Supporting individuals with multiple chronic conditions requires a patient-centered approach,” said Barbara McCann, co-chair of the Multiple Chronic Conditions Steering Committee. “This framework will be vital in helping public and private sector quality improvement initiatives shift from a disease-specific model and ultimately improving care for this population.”

Medscape Physician Compensation Report Physicians Skeptical of ACO Model

Medscape, WebMD’s flagship site for medical professionals, issued a report in the end of April highlighting the opinions of 24,000 U.S. physicians regarding their compensation, and opinions on healthcare reform, including Accountable Care Organizations (ACOs) and treatment guidelines.  The survey was conducted from Feb. 1-17, 2012 via an online survey from a third-party collection site. The respondents represented 25 different physician practice areas.  Below is a summary of findings. 

Medscape Physician Compensation Report 

ACO’s: Currently, only about 3% of physicians participate with ACOs, which are a type of payment and delivery model that ties provider reimbursement to quality metrics and reduction in the total cost of care for an assigned patient population; they may initiate bundling of payments for various clinical outcomes.  Another 5% say that they plan to become involved in the coming year.  52% percent of physicians believe that ACOs will cause a decline in income, while 12% say they will have little or no effect.  "Most people are averse to change, and doctors are the same," says Bohannon. "Until more ACOs are up and running, you can expect resistance and skepticism." 

Quality Measures:  Physicians are skeptical about whether quality measures and treatment guidelines will improve patient care. Close to half of doctors say that they will have a negative impact on care, while 22% believe that they will lead to better-quality care.  Elements of healthcare reform entail following treatment and quality guidelines set by insurers and Medicare for shared savings programs, but physicians are clearly skeptical that they will improve patients' quality of care. 

• Almost half of physicians surveyed (47%) said these measures will have a negative impact,
• whereas 29% said it will have no impact on quality.
• Only 25% of physicians believe it will lead to better-quality care. 

Between 26% and 31% of internists, family physicians and pediatricians say that quality measures and treatment guidelines will have a positive effect.  "No physician likes being told how to treat patients," says Bohannon. "They fear that guidelines are promoted for cost-cutting reasons rather than the patient's best interest. Physicians already give up so much autonomy going from a profession that was mainly private practice to one where they're more likely to be employed. They see the guidelines as a greater loss of autonomy." 

Healthcare reform’s “unnecessary care” goal met with skepticism – One healthcare reform goal of reducing “unnecessary care" garners negative response from physicians. The vast majority (67 percent) of physicians said they won't reduce the amount of tests, procedures, and treatments they perform in order to comply with insurer treatment guidelines, either because the guidelines aren't in their patients' best interests or because doctors still need to practice defensive medicine.  Only about a quarter of doctors (27%) said that they would reduce the number of tests and procedures because the guidelines are valid.

Private Practice: Although physicians are rushing toward employment, partners in private practice far outearned physicians in any other work environment. "Owners of practices are busier than hospital-employed doctors," said Bohannon. "Medium-sized groups do well because of economies of scale and greater bargaining power with health plans." 

• Partners in private practice earned a mean of $308,000.
• Solo-practice owners earned a mean of $222,000,
• Employed physicians earned a mean of $194,000.

 Board-Certification: Physicians who are board certified earned a mean of $236,000; that's 89% more than non-board-certified doctors, who earned a mean of $125,000. Board certification has great impact on more than just compensation. It is often required for inclusion in health plans and for hospital privileges. "As patients are becoming savvier, they research physicians' backgrounds. Board certification becomes more important," said Bohannon. 

Specialties: The top-earning specialties in 2012 were the same as in the previous year, although their incomes declined in general.  In 2012, radiologists and orthopedic surgeons again topped the list at a mean income of $315,000, followed by cardiologists ($314,000) and anesthesiologists ($309,000). The same four specialties were in the leading positions in last year's survey. The bottom-earning specialties also remained similar: pediatrics ($156,000), family medicine ($158,000), and internal medicine ($165,000). 

Some salaries are down, but other specialties saw gains:  The biggest income increases were in ophthalmology (up 9 percent to $270,000) and pediatrics (up 5 percent to $156,000). Nephrology ($209,000), oncology ($295,000), and rheumatology ($180,000), were all up 4 percent. The largest declines were in general surgery (down 12 percent to $265,000); orthopedic surgery ($315,000) and radiology ($315,000), both down 10 percent; and neurology (down 8 percent to $184,000). 

Gender Gap: Overall, male physicians earn 40 percent more than female physicians, although that difference is only 23 percent in primary care. Experts say that the difference is related to choice of specialties and lifestyle preferences, and that if female physicians worked the same number of hours as men, they'd likely earn about the same.  Also, these experts point out that young male physicians are making similar lifestyle decisions to females, in choosing to work less, which could lead to a decrease in compensation gap in the future. However, the gap in income is narrower in some specialties. Male obstetricians/gynecologists earned about 12% more than their female counterparts in 2012, and male pathologists earned about 8% more than females.  

Geography: The highest-earning physicians practice in the North Central region, comprising Iowa, Missouri, Kansas, Nebraska, and South and North Dakota, at a mean income of $234,000, up slightly from the 2011 report. The next highest earners are doctors in the South Central and Great Lakes region at a mean of$228,000. Physicians in the Northeast earn the least, at a mean of $204,000. "There's less competition among physicians in smaller communities and rural areas," says Bohannon. "There isn't that same downward pressure on reimbursement that you have in metropolitan areas. Generally, smaller communities have to pay more to attract physicians." 

More Physicians are questioning their career choice: In 2012, just over half of all physicians (54 percent) would choose medicine again as a career, far less than in the previous year's report, where 69 percent of physicians would choose medicine again. 

• Only one quarter of internists and one third of family physicians would choose the same specialty.
• Despite lower incomes, 46% of pediatricians would still choose that specialty.
• About 23% of all doctors would choose the same practice setting, compared with 50% a year ago.
• There was little difference in attitude between male and female physicians.
• The most frustrated with their specialties were internists and family physicians. 

Satisfaction: Last year's satisfaction scores hit 80% (dermatologists), with many other specialties over 70% (radiologists and oncologists) and several over 60%. In Medscape's 2012 survey, however, there are fewer smiles. 

• The most satisfied specialty is again dermatology, but this time with a satisfaction score of 64% -- considerably down from 80%.
• Close to half the specialties surveyed scored under 50% in overall satisfaction.
• The most discontented were plastic surgeons; only 41% said that they were satisfied overall.
• Internists (44%) and
• Endocrinologists (45%) also expressed lower levels of satisfaction. 

“Rich” Doctor: Overall, only about 11% of physicians said that they consider themselves rich, while 45% said that their income is no better than that of many nonphysicians.  Another 45% said that although their income probably qualifies them as rich, they have so many debts and expenses that they don't feel rich.  The specialties with the highest percentage of physicians who consider themselves rich were 

-       pathology (15%),

-       radiology, oncology and gastroenterology (14% in each).

-       Even among some of the higher-earning specialties, a majority of anesthesiologists, critical care specialists, dermatologists, urologists, and emergency medicine doctors said that they don't feel rich because of debts and expenses. 

Time: About 3 in 10 physicians (31%) spend 30-40 hours per week in direct patient care, a slightly higher percentage than in Medscape's 2011 survey. One quarter of critical care specialists spend more than 65 hours per week seeing patients, as do 11% of general surgeons and cardiologists and 10% of internists and nephrologists. About one quarter of pediatricians, rheumatologists, and family physicians spend less than 30 hours per week in direct patient care. 

Patient Load: Just less than one third (29%) of all physicians see 50-99 patients per week. In the 2011 survey, about 40% of doctors saw that many patients per week. About 23% of physicians see 100-174 patients per week. Radiologists have the most patient visits: One in 5 sees more than 200 patients per week. 

Reimbursement: Although decreased reimbursement has been the recent buzz-phrase, some specialties saw modest gains, whereas others saw significant declines. The biggest income increases were in: ophthalmology (+9%), pediatrics (+5%), nephrology (+4%), rheumatology (+4%), and oncology (+4%). For declines, the largest were in general surgery (-12%), orthopedic surgery (-10%), radiology (-10%), and emergency medicine (-8%). 

Patient Time: As in Medscape's 2011 survey, the 13- to 16-minute patient visit is still the most common, especially in the primary care specialties of family medicine and internal medicine. Anesthesiologists (49%), critical care physicians (44%), and neurologists (46%) spend more time with each patient: a mean of 25 minutes or more. A majority of dermatologists (40%), radiologists (8%), ophthalmologists (35%), and emergency physicians (35%) spend the least time -- a mean of 9-12 minutes per encounter.  The amount of time per patient visit excludes the patient's time with a nurse practitioner, physician assistant, or medical assistant; it measures only time spent in the presence of a physician.  These data do not include psychiatrists. 

Administrative: More than half of physicians spend a minimum amount of time - 4 hours or less - on paperwork and other administrative activities. Another 23% spend from 5 to 14 hours per week on administrative work. HIV/AIDS physicians (27%) spend at least 25 hours per week, followed by pathologists (33%) and oncologists (18%). Only 10% of family physicians, internists, and pediatricians spend that much time on administrative activity. "More documentation is being required than ever before, and paperwork demands have definitely increased," says Bohannon.

 

Continuing Medical Education: ACP Looks at New Models to Achieve Quality Improvement

A recent article from the American College of Physicians look at new models of continuing medical education (CME), which seek not only to impart knowledge but to change physicians’ behavior and even play a role in facilitating organizational improvement.  These CME models thus share some of the same basic goals as the field of quality improvement (QI), namely behavioral change and systems redesign to improve patient outcomes. 

The article provides some practical ideas about how CME providers and QI experts may beneficially integrate these two fields.  The article outlines several models for harnessing the existing engagement in traditional CME to achieve the goal of equipping practitioners with knowledge and skills related to QI, while also addressing the widely recognized problems with traditional CME. The authors touch on possible incentives to make such integrated models of CME and QI attractive to practitioners. 

Background 

Physicians acquire new knowledge and skills and, thus, improve patient care by participating in CME.  As we have noted several times, CME has positive outcomes on physician practice and patient outcomes, with positive results usually associated with multiple teaching methods that incorporate interactive engagement of learners.  Despite success, some have called for major reform of CME, including the development of new models that emphasize more active participation than traditional didactic formats, promoting self-directed learning on topics relevant to participants’ routine practice. These new models of CME seek not only to change behavior but to play a role in reorganizing care to improve patient outcomes. 

The burgeoning field of quality improvement (QI) similarly seeks to improve patient care through reorganizing care delivery and changing physician behavior, however, “CME programs still rarely teach principles of QI, and most practicing physicians remain unfamiliar with them.”  Reviews of CME literature highlight the lack of relevant conceptual models for influencing behavior as the explanation for why so few programs change practice or improve outcomes. One recent framework sets CME in the context of a complex adaptive system in which many aspects of practice environments, along with appropriate resources, must be aligned to sustain changes in physician behavior. 

In response to the limitations of traditional formats, the scope of CME has broadened to include audit and feedback, opinion leaders, multifaceted interventions, reminders, and other more novel approaches. Online CME is also increasingly common.  However, a recent meta-analysis of more than 200 studies found that Internet-based education had similar effects as traditional CME on knowledge and skills and only modest effects on patient outcomes. Overall, designing and implementing CME programs that foster changes in practice patterns and improved patient outcomes remains challenging. 

From the beginning, the QI field has focused on improving patient outcomes by directly affecting physician behavior or redesigning practice systems to foster reliable delivery of optimal processes of care.  Yet, despite widespread attention to health care quality over the past decade, the language, goals, and tools of QI remain foreign to many physicians.  A national survey published in 2005 reported that only one third of physicians had ever undertaken QI projects in their practices. 

While the American Board of Medical Specialties has made practice improvement a requirement for maintenance of certification for more than a decade, the practice improvement component remains a new and frequently challenging experience among candidates for recertification. Many physicians remain unequipped to engage in improvement activities in their practices. 

CME and QI 

A growing number of educational efforts impart basic concepts and methods of QI to practitioners and trainees.  Successful programs have adopted principles of adult learning, combining experiential learning with didactic sessions.  The best outcomes are when learners received individualized coaching, performance data, or process improvement tools, such as educational material for patients and decision support for clinicians.  However, educational efforts to teach QI to clinicians have remained largely restricted to academic or large health systems. Engaging community-based physicians in learning QI occurs less frequently and poses greater challenges. 

While physicians face quality problems in their practice, most physicians are unlikely to participate in a CME program that is explicitly focused on QI methods.  As a result, the authors suggested that exposure to and participation in QI activities be embedded in CME focused on clinical content areas.  Accordingly, the article outlined models with 4 levels of increasing ambitiousness and physician engagement. The lower levels are less resource-intensive and can be implemented relatively easily within traditional CME programs.  The higher levels require resources and infrastructure to support the experiential components. 

1. 1.    Highlight Clinical Areas With Quality Problems in Traditional CME 

Attendees at CME conferences seek to update their knowledge of a particular disease or specialty area.  The topics covered at such conferences overwhelmingly consist of new treatment methods (drugs or devices) and advances in diagnostic technologies. However, other topics present important clinical information while also delivering content related to health care quality.  For instance, a diabetes CME program, in addition to covering recent developments with new classes of drugs and technologies, can include sessions designed to improve patient outcomes by optimizing reduction of cardiovascular risk factors or assessing and managing comorbid depression. Programs can also present practical strategies for recognizing the need to intensify glycemic control.  These topics do not teach QI skills per se, but they promote attention to clinical issues involving well-documented gaps in quality for patients with diabetes.  This approach can be applied to CME programs tailored for both generalists and specialists. 

1. 2.    Explicitly Add QI Content in CME on Specific Clinical Topics

While highlighting gaps in quality represents a reasonable start, physicians need skills to act on this information.  CME programs on clinical topics could include sessions that show participants how to identify quality gaps in their own practices and cover specific methods to address these problems.  For example, a program on diabetes could teach chart auditing focused on key processes of care or the adequacy of glycemic control. 

The material could include examples of common reasons for suboptimal performance and outline strategies for addressing these problems.  Where evidence supports specific improvement strategies—for example, some forms of case management for diabetes and heart failure clinics—sessions may focus on practical aspects of implementing these strategies. With this approach, participants would learn specific tools to implement QI in the context of acquiring new knowledge on clinical topics that interest them. 

1. 3.    Supplement CME With Postevent Deliverables 

Postevent deliverables, such as submitting results of QI projects after a CME course, would provide physicians with experience in applying QI in their own practices.  For example, participants in a course on diabetes may learn about structured practice audits focused on evidence-based performance measures and strategies to address quality

gaps identified in the audit.  After the CME program, participants could conduct audits in their practices, develop improvement plans, and potentially submit their plans to CME providers.  Such activities could be aligned with maintenance of certification so that participants receive credit for a component of the recertification process. This approach requires further investment of physicians’ time but has the advantage of truly engaging physicians in QI activities in their own settings. 

1. 4.    Embed CME Activities in Larger QI Initiatives 

Coordination of CME with larger-scale QI initiatives offers another potential strategy to engage physicians.  For instance, a specialty organization could target a particular quality problem and develop a multi-component QI strategy that integrates CME with online best evidence resources, toolkits related to specific improvement strategies, and the establishment of learning communities for physicians to share their experiences as they try to implement improvements. The American College of Physician’s Closing the Gap program represents one such example, as does the American College of Cardiology’s Door-to-Balloon project, which linked participation in a disease registry and nationwide QI program with CME credit and demonstrated substantial improvements in the target process of care.  Other examples of CME activities linked to broader QI initiatives have involved primary care for diabetes and asthma and management of acute gastroenteritis in children. 

Conclusion 

Greater integration of CME and QI offers the opportunity to improve health care quality and simultaneously address the widespread calls for changes in CME.  The Accreditation Council for Continuing Medical Education recently began pushing CME providers to establish quality metrics in planning and evaluating educational activities. 

To achieve this integration, a culture shift will be necessary and CME providers will also incur costs.  

Continuing medical education may ultimately move away from traditional lecture-based formats in favor of activities that demonstrate target competencies (6), including skills in QI.  Support from organizations with a commitment to QI, such as large health care systems, professional organizations, or health care payers, as well as incentives for participants based on additional CME credits or credentialing benefits, could help moderate cost increases and overcome resistance among physicians.  Realistically, additional incentives may be required. 

For example, the government of Ontario, Canada, has launched a program in which physicians engaged in certain types of QI activities can receive financial compensation for their time.  The gesture of compensating for physicians’ time, as much as the modest remuneration itself, has resulted in the participation of approximately one third of eligible physicians.  Learning collaboratives can also support physicians by linking them with colleagues who are engaged in similar QI activities to share experiences of overcoming barriers to implementing specific changes in practice. 

Ultimately, while the three proposed examples of integration between CME and QI incorporate traditional meeting-based CME, they all depart from tradition by emphasizing clinical topics relevant to improving care, rather than the longstanding narrow focus on new therapeutics, and by providing skills that support clinicians’ efforts to improve their practices. The authors concluded by asserting that, “these changes would meet the growing calls for CME reform and simultaneously make teaching QI more accessible to physicians who seek to provide high-quality patient care.”

Choosing Wisely: Associations Join to Educate Physicians and Pateints on Unnecessary Tests and Treatments

A recent initiative lead by the American Board of Internal Medicine Foundation (ABIM Foundation) and in partnership with Consumer Reports, aims at reducing unnecessary medical treatment, which some estimate constitutes one-third of medical spending in the U.S.  This includes unnecessary hospitalizations and tests, unproven treatments, ineffective new drugs and medical devices, and futile care at the end of life.  Some claim that doctors perform 45 common tests and procedures less often. 

The initiative, called Choosing Wisely, urges patients to question these services if they are offered.  The initiative has garnered 9 professional medical specialty partners with 8 others preparing to follow.  These partners include: 

• American Academy of Allergy, Asthma & Immunology
• American Academy of Family Physicians
• American College of Cardiology
• American College of Physicians
• American College of Radiology
• American Gastroenterological Association
• American Society of Clinical Oncology
• American Society of Nephrology
• American Society of Nuclear Cardiology 

These specialty societies represent 374,000 physicians.  Each society has developed a list of "Five Things Physicians and Patients Should Question" which patients can access from the choosingwisely.org website.   Additionally, eight new specialty societies have joined the campaign and will be releasing lists in fall 2012: 

• American Academy of Hospice and Palliative Medicine
• American Academy of Otolaryngology–Head and Neck Surgery
• American College of Rheumatology
• American Geriatrics Society
• American Society for Clinical Pathology
• American Society of Echocardiography
• Society of Hospital Medicine
• Society of Nuclear Medicine  

A recent article in the Journal of the American Medical Association (JAMA), also discussed the new initiative.  The article explained how the origins of this campaign are from the “Medical Professionalism in the New Millennium: A Physician Charter.”  Authored in 2002 by the ABIM Foundation, American College of Physicians Foundation, and European Federation of Internal Medicine, the charter has as its fundamental principles the primacy of patient welfare, patient autonomy, and social justice. 

It articulates the professional responsibilities of physicians, including a commitment to improving quality and access to care, advocating for a just and cost-effective distribution of finite resources, and maintaining trust by managing conflicts of interest.  The charter's commitment to a just distribution of finite resources specifically calls on physicians to be responsible for the appropriate allocation of resources and to scrupulously avoid superfluous tests and procedures. 

“Overuse is one of the most serious crises in American medicine,” said Dr. Lawrence Smith, physician-in-chief at North Shore-LIJ Health System and dean of the Hofstra North Shore-LIJ School of Medicine, who was not involved in the initiative.  “Many people have thought that the organizations most resistant to this idea would be the specialty organizations, so this is a very powerful message.”

“Many previous attempts to rein in unnecessary care have faltered, but guidance coming from respected physician groups is likely to exert more influence than directives from other quarters.  But their change of heart also reflects recent changes in the health care marketplace.” 

The list of tests and procedures they advise against includes EKGs done routinely during a physical, even when there is no sign of heart trouble, M.R.I.’s ordered whenever a patient complains of back pain, and antibiotics prescribed for mild sinusitis — all quite common.

The American College of Cardiology is urging heart specialists not to perform routine stress cardiac imaging in asymptomatic patients, and the American College of Radiology is telling radiologists not to run imaging scans on patients suffering from simple headaches.  The American Gastroenterological Association is urging its physicians to prescribe the lowest doses of medication needed to control acid reflux disease.

Even oncologists are being urged to cut back on scans for patients with early stage breast and prostate cancers that are not likely to spread, and kidney disease doctors are urged not to start chronic dialysis before having a serious discussion with the patient and family.

Other efforts to limit testing for patients have provoked backlashes.  In November 2009, new mammography guidelines issued by the U.S. Preventive Services Task Force advised women to be screened less frequently for breast cancer, stoking fear among patients about increasing government control over personal health care decisions and the rationing of treatment.

“Any information that can help inform medical decisions is good — the concern is when the information starts to be used not just to inform decisions, but by payers to limit decisions that a patient can make,” said Kathryn Nix, health care policy analyst for the Heritage Foundation a conservative research group. 

“With health care reform, changes in Medicare and the advent of accountable care organizations, there has been a strong push for using this information to limit patients’ ability to make decisions themselves.” 

Some of the tests being discouraged — like CT scans for someone who fainted but has no other neurological problems — are largely motivated by concerns over a malpractice lawsuits, experts said. Clear, evidence-based guidelines like the ones to be issued Wednesday will go far both to reassure physicians and to shield them from litigation. 

“These all sound reasonable, but don’t forget that every person you’re looking after is unique,” said Dr. Eric Topol, chief academic officer of Scripps Health, a health system based in San Diego, adding that he worried that the group’s advice would make tailoring care to individual patients harder.  “This kind of one-size-fits-all approach can be a real detriment to good care.”

Cancer patients also expressed concern that discouraging the use of experimental treatments could diminish their chances at finding the right drug to quash their disease.

“I was diagnosed with Stage IV breast cancer right out the gate, and I did very well — I was what they call a ‘super responder,’ and now I have no evidence of disease,” said Kristy Larch, a 44-year-old mother of two from Seattle, who was treated with Avastin, a drug that the F.D.A. no longer approves for breast cancer treatment. “Doctors can’t practice good medicine if we tie their hands.” 

“By identifying tests and procedures that might warrant additional conversations between doctors and patients, we are able to help patients receive better care through easy-to-use and accessible information,” said James A. Guest, J.D., president and CEO of Consumer Reports. “We’re looking forward to being a part of this innovative effort working with the ABIM Foundation, the specialty societies, and our eleven consumer communications collaborators to get this important message out to diverse populations of patients.”

National Quality Forum Adopts Four New Quality Measures

The National Quality Forum (NQF) recently added to its list an additional four measures that focus on patients with asthma, chronic obstructive pulmonary disease (COPD), hip/knee replacement and pneumonia.  NQF is a voluntary consensus standards-setting organization. 

Resource use measures as defined by NQF are comparable measures of actual dollars or standardized units of resources applied to the care given to a specific population or event, such as a specific diagnosis or procedure.  NQF said these new measures will provide vital data on how resources are used in these areas of care.  Such data will help create a more efficient, less wasteful healthcare system.  

These measures were endorsed as part of a larger NQF endorsement project to evaluate how resources are used in care delivery, as a result of keen interest from government and private payers.  Several provisions in recent policy require use of resource data over the next several years to support efforts to move toward a value-based purchasing payment model, and private payers have been using these types of measures for several years. 

Any party may request reconsideration of any of the four endorsed quality measures listed below by submitting an appeal no later than May 1 (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. 

With the goal of measuring how efficiently providers and payers perform, NQF in 2009 sought to identify and evaluate resource use measures, that is, comparable measures of actual dollars or standardized units of resources regarding the care of a specific population or event. 

The standards-setting organization in January had endorsed resource use measures for diabetes, cardiovascular conditions, population-based per member per month index, as well as total cost per population-based per member per month index.

The four new measures were added to the list of voluntary standards to "offer a more complete picture of what is driving healthcare costs,” the resource use brief states. While it noted there are diverse perspectives on costs and resource use, NQF said it acknowledged the submitted measures are only a narrow perspective in curbing healthcare expenditures, helping stakeholders identify opportunities to cut costs and improve quality.

“Healthcare spending in the United States continues to rise without any significant gains in patient satisfaction, increased access to care, or higher-quality care,” NQF President and CEO Janet Corrigan said in a statement. “I'm confident that these additional measures--in conjunction with existing resource use measures in our portfolio--will help us better understand what is driving costs and create a more effective, efficient healthcare system.” 

NQF this week also approved 14 perinatal measures, including childbirth, pregnancy and post-partum and newborn care, as well as 12 renal care measures, such as chronic kidney disease, end stage renal disease and dialysis treatment.  The renal care measures will help ensure renal patients receive safe, high-quality, and compassionate care throughout the course of treatment. 

For this project, NQF endorsed measures focused on care concerns such as mortality rates for facility dialysis patients, and hemoglobin levels in chronic kidney disease patients. NQF also endorsed measures related to vascular access and minimum dose with dialysis treatment and lipid profiles in chronic kidney disease patients. In all, 33 measures were evaluated against NQF’s endorsement criteria by a panel of providers, measurement experts, and consumer representatives; 12 measures were endorsed.