Opinion
VIEWPOINT
Christine G. Gourin, MD, MPH Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland. Marion E. Couch, MD, PhD, MBA Department of Otolaryngology–Head and Neck Surgery, Indiana University, Indianapolis.
Defining Quality in the Era of Health Care Reform The United States faces a fiscal crisis due to unsustainable growth in federal spending at rates significantly higher than inflation. Entitlement spending represented nearly 62% of the federal budget in 2012.1 Medicare accounts for the majority of federal health care spending with the fastest rate of growth because of increased enrollment and utilization of services, increased severity of illness and treatment intensity, and faster growth in prices.2 At the same time, the quality of US health care has been called into question following a series of landmark reports by the Institute of Medicine (IOM). These observations underlie current health care reform efforts.
Pay for Performance
Corresponding Author: Christine G. Gourin, MD, Johns Hopkins Outpatient Center, Department of Otolaryngology–Head and Neck Surgery, 601 N Caroline St, Ste 6260, Baltimore, MD 21287 ([email protected]). jamaotolaryngology.com
The Affordable Care Act (ACA) includes a series of Medicare reforms aimed at reducing the rate of growth in Medicare spending, utilizing payment cuts and new rules governing physicians, hospitals, and insurance plans, with the most immediate reforms addressing physician and hospital participation in voluntary reporting of core set of health quality and performance measures. This pay-for-performance model includes 285 measures that emphasize adherence to single point of care process measures. For hospitals, 30% of the score is determined by patient satisfaction and 25% by mortality rates, which inevitably will apply to physicians as well. There is limited empirical evidence that these programs actually improve value, and a recent Congressional Budget Office (CBO) report showed that none of the Medicare incentive-based pay for performance demonstration projects yielded significant savings, and they do not always assess whether care was appropriate.3 Hospitals and clinicians that treat high risk patients with multiple medical comorbidities or requiring more complex care may be unduly burdened or penalized. Unintended consequences of these policies have been reported such as lower use of coronary revascularization in high-risk patients, or increased use of palliative care codes to triage the sickest patients at greatest risk of in-hospital mortality to hospice care.3,4 The risks of a pay-for-performance model in a feefor-service environment is the potential for unfair burden on those physicians who treat sicker and more complex patients, the potential for reduced access to care for the highest risk patients, and the diversion of resources away from patient care toward programs that ensure compliance. Pay-for-performance may not curb health care spending in the context of the fee-for-service model it operates in, because there is no incentive to reduce volume of services. The Dartmouth Atlas of Health Care project has highlighted great variation in Medicare spending across the country that was almost entirely explained by the volume
of services received for a given condition, which was positively associated with hospital bed and specialist number and negatively associated with adherence to evidence-based guidelines, mortality, coordination of care among physicians, access, and patient experiences. 5 The IOM reported that 30% of total health care spending in 2009, or $765 billion dollars, was wasteful spending with unnecessary services, excessive administrative costs associated with billing and insurance, and inefficiently delivered services including poor coordination of care accounting for 80% of waste.6 Successfully eliminating health care waste would have the single greatest impact on health care reform and quality improvement, but may not be realized in the context of existing fee-for-service health care models which reward volume.
Bundled Payment Models Bundled payment models have received increased attention by Centers for Medicare & Medicaid Services (CMS), in which a single comprehensive payment covers services furnished by multiple providers during a defined episode of care for a given disease process. Bundled payments include financial and performance accountability for episodes of care, with built-in incentives such as working with community resources to coordinate the care of a patient and reducing the incidence of adverse outcomes. The bundled payment model is the only value-based payment model reported by the CBO to result in significant savings for Medicare.3 By reimbursing a set amount for an episode of care, decisions about how care will be provided and what constitutes an episode of care are at the discretion of the providers and administrative burdens should theoretically be reduced. The goal of bundled payment models is to reward value over volume, but bundled payment models have the potential to be complex, with unintended effects of underuse of services, avoidance of high-risk patients, and increases in the volume of bundles reimbursed. Defining bundles will require careful thought with inclusion of evidence-based care protocols, comparative effectiveness research, decision support tools, patient engagement, and physician involvement.6 Engaging patients and their families in care decisions and the management of their conditions often leads to greater patient satisfaction about the care they receive, and can lead to better outcomes and reduced costs. Physicians must be involved in these discussions and identify costly treatments with little to no benefit for patients, in order to control health care costs and assure continued funding for care known to be of value. The effectiveness of bundled payment models depends on how well episodes are defined and how well the care for a given episode correlates with quality.
JAMA Otolaryngology–Head & Neck Surgery November 2014 Volume 140, Number 11
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archotol.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 06/02/2015
997
Opinion Viewpoint
Otolaryngology-Specific Quality Measures Although some quality measures may apply across surgical specialties, measurement sets specific to each surgical specialty must be created that can be used to evaluate the entire spectrum of care for the conditions we treat. The emphasis on quality and the specter of bundled payments require that we move beyond simply looking at short-term visit-based outcomes and turn a critical eye on all of the services we provide. Services identified as low-value by the American Academy of Otolaryngology–Head and Neck Surgery in response to the “Choosing Wisely” campaign are limited to imaging and antibiotic use, but not procedures, similar to the response of other specialty societies. We need to identify best practices, provide a framework to define episodes of care, and develop patientcentered quality indicators that reflect the care that should happen and to whom, inform how care should be provided, and define the care that should not be provided in order to demonstrate thoughtful use of resources without supporting inappropriate or unnecessary care. Significant resources will be needed to support otolaryngologyspecific quality indicator development for quality measure implementation. The development of otolaryngology quality measures requires patient and other stakeholder input to identify services that
Conclusions Physicians must take an active role in the process of health care reform, or leave decision-making to others and accept definitions of quality that we may not agree with. It is incumbent upon all of us to play an active and participatory role in defining high-quality otolaryngology care, supported by strong evidence, that is appropriate and beneficial to patients while at the same time recognizing care that is unnecessary and contributes to waste, so that we are able to effectively negotiate on behalf of our patients.
-Reports/NationalHealthExpendData/downloads /proj2012.pdf. Accessed May 12, 2014.
ARTICLE INFORMATION Published Online: September 25, 2014. doi:10.1001/jamaoto.2014.2086. Conflict of Interest Disclosures: None reported. REFERENCES 1. George R, Coffin J, George S. Value-based purchasing and the doctor-patient relationship. J Med Pract Manage. 2013;28(6):341-344. 2. Centers for Medicare & Medicaid Services. National Health Expenditure Projections 2012-2022. http://www.cms.gov/Research -Statistics-Data-and-Systems/Statistics-Trends-and
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are beneficial, measurable, and supported by evidence that an association exists between the measure and population values, and preferences or outcomes. The reliability and validity of promising measures must then be tested using quality improvement tools and qualitative methods by establishing benchmarks, identifying exclusions, confirming indicator accuracy, and ensuring validity across multiple care settings. Finally, publication of evidence evaluating the reliability and validity of the measure in peer-reviewed journals, and adoption by organizations that promote rigorous development and use of quality measures in health care are final requirements before quality measures can be approved for use to inform health care decisions.7
3. Kupfer JM. The morality of using mortality as a financial incentive: unintended consequences and implications for acute hospital care. JAMA. 2013; 309(21):2213-2214. 4. Dupree JM, Neimeyer J, McHugh M. An advanced look at surgical performance under Medicare’s hospital-inpatient value-based purchasing program: who is winning and who is losing? J Am Coll Surg. 2014;218(1):1-7. 5. Fisher E, Goodman D, Skinner J, Bronner K; Dartmouth Institute for Health Policy & Clinical
Practice. Healthcare spending, quality and outcomes: more isn't always better. http://www .dartmouthatlas.org/downloads/reports/Spending _Brief_022709.pdf. Accessed May 12, 2014. 6. Institute of Medicine. In: Young PL, Olsen L, eds. The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series Summary. Washington, DC: National Academy Press; 2010. 7. Agency for Healthcare Research and Quality, US Department of Health and Human Services. Domain framework and inclusion criteria. http: //www.qualitymeasures.ahrq.gov/about/inclusion -criteria.aspx. Accessed May 12, 2014.
JAMA Otolaryngology–Head & Neck Surgery November 2014 Volume 140, Number 11
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archotol.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 06/02/2015
jamaotolaryngology.com
VIEWPOINT
Christine G. Gourin, MD, MPH Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland. Marion E. Couch, MD, PhD, MBA Department of Otolaryngology–Head and Neck Surgery, Indiana University, Indianapolis.
Defining Quality in the Era of Health Care Reform The United States faces a fiscal crisis due to unsustainable growth in federal spending at rates significantly higher than inflation. Entitlement spending represented nearly 62% of the federal budget in 2012.1 Medicare accounts for the majority of federal health care spending with the fastest rate of growth because of increased enrollment and utilization of services, increased severity of illness and treatment intensity, and faster growth in prices.2 At the same time, the quality of US health care has been called into question following a series of landmark reports by the Institute of Medicine (IOM). These observations underlie current health care reform efforts.
Pay for Performance
Corresponding Author: Christine G. Gourin, MD, Johns Hopkins Outpatient Center, Department of Otolaryngology–Head and Neck Surgery, 601 N Caroline St, Ste 6260, Baltimore, MD 21287 ([email protected]). jamaotolaryngology.com
The Affordable Care Act (ACA) includes a series of Medicare reforms aimed at reducing the rate of growth in Medicare spending, utilizing payment cuts and new rules governing physicians, hospitals, and insurance plans, with the most immediate reforms addressing physician and hospital participation in voluntary reporting of core set of health quality and performance measures. This pay-for-performance model includes 285 measures that emphasize adherence to single point of care process measures. For hospitals, 30% of the score is determined by patient satisfaction and 25% by mortality rates, which inevitably will apply to physicians as well. There is limited empirical evidence that these programs actually improve value, and a recent Congressional Budget Office (CBO) report showed that none of the Medicare incentive-based pay for performance demonstration projects yielded significant savings, and they do not always assess whether care was appropriate.3 Hospitals and clinicians that treat high risk patients with multiple medical comorbidities or requiring more complex care may be unduly burdened or penalized. Unintended consequences of these policies have been reported such as lower use of coronary revascularization in high-risk patients, or increased use of palliative care codes to triage the sickest patients at greatest risk of in-hospital mortality to hospice care.3,4 The risks of a pay-for-performance model in a feefor-service environment is the potential for unfair burden on those physicians who treat sicker and more complex patients, the potential for reduced access to care for the highest risk patients, and the diversion of resources away from patient care toward programs that ensure compliance. Pay-for-performance may not curb health care spending in the context of the fee-for-service model it operates in, because there is no incentive to reduce volume of services. The Dartmouth Atlas of Health Care project has highlighted great variation in Medicare spending across the country that was almost entirely explained by the volume
of services received for a given condition, which was positively associated with hospital bed and specialist number and negatively associated with adherence to evidence-based guidelines, mortality, coordination of care among physicians, access, and patient experiences. 5 The IOM reported that 30% of total health care spending in 2009, or $765 billion dollars, was wasteful spending with unnecessary services, excessive administrative costs associated with billing and insurance, and inefficiently delivered services including poor coordination of care accounting for 80% of waste.6 Successfully eliminating health care waste would have the single greatest impact on health care reform and quality improvement, but may not be realized in the context of existing fee-for-service health care models which reward volume.
Bundled Payment Models Bundled payment models have received increased attention by Centers for Medicare & Medicaid Services (CMS), in which a single comprehensive payment covers services furnished by multiple providers during a defined episode of care for a given disease process. Bundled payments include financial and performance accountability for episodes of care, with built-in incentives such as working with community resources to coordinate the care of a patient and reducing the incidence of adverse outcomes. The bundled payment model is the only value-based payment model reported by the CBO to result in significant savings for Medicare.3 By reimbursing a set amount for an episode of care, decisions about how care will be provided and what constitutes an episode of care are at the discretion of the providers and administrative burdens should theoretically be reduced. The goal of bundled payment models is to reward value over volume, but bundled payment models have the potential to be complex, with unintended effects of underuse of services, avoidance of high-risk patients, and increases in the volume of bundles reimbursed. Defining bundles will require careful thought with inclusion of evidence-based care protocols, comparative effectiveness research, decision support tools, patient engagement, and physician involvement.6 Engaging patients and their families in care decisions and the management of their conditions often leads to greater patient satisfaction about the care they receive, and can lead to better outcomes and reduced costs. Physicians must be involved in these discussions and identify costly treatments with little to no benefit for patients, in order to control health care costs and assure continued funding for care known to be of value. The effectiveness of bundled payment models depends on how well episodes are defined and how well the care for a given episode correlates with quality.
JAMA Otolaryngology–Head & Neck Surgery November 2014 Volume 140, Number 11
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archotol.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 06/02/2015
997
Opinion Viewpoint
Otolaryngology-Specific Quality Measures Although some quality measures may apply across surgical specialties, measurement sets specific to each surgical specialty must be created that can be used to evaluate the entire spectrum of care for the conditions we treat. The emphasis on quality and the specter of bundled payments require that we move beyond simply looking at short-term visit-based outcomes and turn a critical eye on all of the services we provide. Services identified as low-value by the American Academy of Otolaryngology–Head and Neck Surgery in response to the “Choosing Wisely” campaign are limited to imaging and antibiotic use, but not procedures, similar to the response of other specialty societies. We need to identify best practices, provide a framework to define episodes of care, and develop patientcentered quality indicators that reflect the care that should happen and to whom, inform how care should be provided, and define the care that should not be provided in order to demonstrate thoughtful use of resources without supporting inappropriate or unnecessary care. Significant resources will be needed to support otolaryngologyspecific quality indicator development for quality measure implementation. The development of otolaryngology quality measures requires patient and other stakeholder input to identify services that
Conclusions Physicians must take an active role in the process of health care reform, or leave decision-making to others and accept definitions of quality that we may not agree with. It is incumbent upon all of us to play an active and participatory role in defining high-quality otolaryngology care, supported by strong evidence, that is appropriate and beneficial to patients while at the same time recognizing care that is unnecessary and contributes to waste, so that we are able to effectively negotiate on behalf of our patients.
-Reports/NationalHealthExpendData/downloads /proj2012.pdf. Accessed May 12, 2014.
ARTICLE INFORMATION Published Online: September 25, 2014. doi:10.1001/jamaoto.2014.2086. Conflict of Interest Disclosures: None reported. REFERENCES 1. George R, Coffin J, George S. Value-based purchasing and the doctor-patient relationship. J Med Pract Manage. 2013;28(6):341-344. 2. Centers for Medicare & Medicaid Services. National Health Expenditure Projections 2012-2022. http://www.cms.gov/Research -Statistics-Data-and-Systems/Statistics-Trends-and
998
are beneficial, measurable, and supported by evidence that an association exists between the measure and population values, and preferences or outcomes. The reliability and validity of promising measures must then be tested using quality improvement tools and qualitative methods by establishing benchmarks, identifying exclusions, confirming indicator accuracy, and ensuring validity across multiple care settings. Finally, publication of evidence evaluating the reliability and validity of the measure in peer-reviewed journals, and adoption by organizations that promote rigorous development and use of quality measures in health care are final requirements before quality measures can be approved for use to inform health care decisions.7
3. Kupfer JM. The morality of using mortality as a financial incentive: unintended consequences and implications for acute hospital care. JAMA. 2013; 309(21):2213-2214. 4. Dupree JM, Neimeyer J, McHugh M. An advanced look at surgical performance under Medicare’s hospital-inpatient value-based purchasing program: who is winning and who is losing? J Am Coll Surg. 2014;218(1):1-7. 5. Fisher E, Goodman D, Skinner J, Bronner K; Dartmouth Institute for Health Policy & Clinical
Practice. Healthcare spending, quality and outcomes: more isn't always better. http://www .dartmouthatlas.org/downloads/reports/Spending _Brief_022709.pdf. Accessed May 12, 2014. 6. Institute of Medicine. In: Young PL, Olsen L, eds. The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series Summary. Washington, DC: National Academy Press; 2010. 7. Agency for Healthcare Research and Quality, US Department of Health and Human Services. Domain framework and inclusion criteria. http: //www.qualitymeasures.ahrq.gov/about/inclusion -criteria.aspx. Accessed May 12, 2014.
JAMA Otolaryngology–Head & Neck Surgery November 2014 Volume 140, Number 11
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archotol.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 06/02/2015
jamaotolaryngology.com
