3/17/2015 1 Presented by Physician Perspective: Clinical Practice Guidelines and Quality of Care Richard E. Moses, D.O., J.D. D. Scott Jones, CHC w w w . hpix-ins . c o m Speakers’ Disclaimer ● Richard E. Moses, DO, JD and D. Scott Jones, CHC do not have any financial conflicts to disclose. ● This presentation is not meant to offer medical, legal accounting, regulatory compliance or reimbursement advice and is not intended to establish a standard of care. Please consult professionals in these areas if you have related concerns. ● The speakers are not promoting any service or product. 2
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3/17/2015
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Presented by
Physician Perspective: Clinical Practice Guidelines and
Quality of Care
Richard E. Moses, D.O., J.D.
D. Scott Jones, CHC
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Speakers’ Disclaimer● Richard E. Moses, DO, JD and D. Scott Jones, CHC do not
have any financial conflicts to disclose.
● This presentation is not meant to offer medical, legal accounting, regulatory compliance or reimbursement advice and is not intended to establish a standard of care. Please consult professionals in these areas if you have related concerns.
● The speakers are not promoting any service or product.
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Presentation Goals
● Examine PPACA and Clinical Practice Guidelines (CPGs)
● Review the impact of PPACA quality reporting mandates, timeliness, and reimbursement penalties
● Discuss the impact of CPGs and other PPACA requirements on quality of care
● Review processes to provide timely CPG, quality information, and education to physicians
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INTRODUCTION
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INTRODUCTION● Background – CPGs, Quality Reporting, and More
● PPACA and Quality Reporting
● PPACA and Physicians
● PPACA and Clinical Practice Guidelines
● PPACA and EHR: Risks, Benefits, & Complications
● PPACA and Physician Risk Education
● Building the Compliance Program of the Future
● CONCLUSIONS & SUMMARY
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PPACA: CPGs, Quality Reporting,
and More
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PPACA: Health Care Reform
● Health Care Reform Goals
• Improve Access
• Universal Coverage
• Increase quality reporting to include outcomes
• Increase integration of care through partnerships of physician networks and hospitals
• Cost control and cost reduction7
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PPACA and Payments● Patient Protection and Affordable Care Act (PPACA 2010) was
amended by the Health Care and Education Affordability Reconciliation Act (HCERA 2012)• 21.3% scheduled reduction in Medicare physician pay (postponed by the
Continuing Extension Acts, 2010‐2014)
• Quality and Cost Payment (Title III, §§ 3002, 3003, 3007) – Adjusts physician payments based on quality and cost through a value‐based modifier, beginning January 1, 2015
• PQRS – penalties for not reporting beginning in 2015 up to 2% of the prevailing fee schedule
• Increase from 260.2 Million Americans with health insurance to 292.6 Million under PPACA • US Census Bureau 2012 Current Population Survey, Annual Social and
Economic Supplement
• 32‐40 Million Americans acquire new health insurance benefits with PPACA; proof of insurance required 2015
• U.S. physician workload expected to increase by 29% from 2005‐2025
• More than 50% of physicians are health system employees
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From Fee Based to Quality Based
● Fee‐for‐service → Value‐based/Quality‐based reimbursement system
• Reward doctors and hospitals for improving quality of care
• Lower demand for inpatient hospital services, higher demand for outpatient services
• Increased number of insured patients
• Improving patient experience key to preserving reimbursement
• Public outcomes reports = hospital competition on outcomes and total value
• Clinically Integrated Networks and Population Health Initiatives
10Health Affairs October 11, 2012
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PPACAand
Quality Reporting
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Hospital Value‐Based Purchasing
● PPACA Title III, Subtitle A: Transforming the Health Care Delivery System• Incentive Payments to Hospitals meeting performance standards in
• Assessment of continuity and coordination of care
• Assessment of efficiency and cost
• Assessment of patient experience
• Assessment of safety, effectiveness, and timeliness of care
• July 1, 2014: User Interface; reports published online
• January 1, 2015: CMS Report to Congress
16www.medicare.gov/physiciancompare
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Physician Compare Website
● CMS must allow physicians & other professionals to have reasonable opportunity to review their results before posting
• 30 day preview period for all measurement data
• October 2015 is next review date
● CMS details of review process
• www.cms.gov
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PPACA Section 10331(a)(2): CG‐CAHPS
● Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG‐CAHPS)• Patient surveys begin 2014…individual physician surveys by 2015
• Timely care, appointments, information
• How well doctors communicate
• Patient ratings of doctors
• Health promotion and education
• Shared decision making
• Health status/functional status as a result of care rendered
● “Certified Survey Vendor” created
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PPACA Rule CMS‐1600‐PQuality Reporting Measures
● Physician Quality Reporting System (PQRS) 2014: • 9 Measures be reported
• 3 from National Quality Strategy domains
• For 50% of the entire Medicare‐eligible patient population
● Effect of not reporting PQRS occurs in 2016
● Failure to report a selection of the measures = up to 2% reduction in prevailing Medicare FS
● Qualified Clinical Data Registries created for sub‐specialists dealing with specific diagnoses, conditions (§ 1848(m)(3)(E)(ii))
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Value Based Modifier (VBS)
● How quality data reported under PQRS equals modification to payments under the FS
● VBS use begins 2015; full implementation 2017
● Physician groups of 10 or more must report beginning 2016; expect all physicians to report by 2017
● Quality tier system results in FS reductions of up to 2%
● QRUR (Quality and Resource Use Reports) will report how the value based modifier will impact individual physician reimbursement
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National Strategy for Quality Improvement in Health Care
● PPACA Part S, Subpart I, Section 399HH(2)(B)(i‐iii)
● Calls for CMS to establish priorities that will:
• Have the greatest potential for improving health outcomes, efficiency, and patient‐centeredness…
• Identify areas…that have the potential for rapid improvement in the quality and efficiency of patient care…
• Address gaps in quality…
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National Strategy for Quality Improvement
● HHS Annual Report to Congress
● “Key Measures and Long Term Goals”
• “…reducing the harm caused in the delivery of care…reduce harm from inappropriate or unnecessary care….”
• CDC: 5% of hospital patients acquire health care associated infections
• 145 Health Care Acquired Conditions (HACs) occur per 1,000 admissions
• Agency for Healthcare Research and Quality (AHRQ): Hospital Readmissions occur at a rate of 14.4%
• Physicians and Compliance Officers are now Quality Officers 22
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PPACA and PHYSICIANS
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“No college junior studies organic chemistry and takes the MCAT planning to devote 4 years to
medical school and 3 plus years to residency and fellowship just to cheat Medicare and
Medicaid.”
Julie K. Taitsman, M.D., J.D.
CMO for the OIG, Department of HHS
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The Physicians Foundation
● National not‐for‐profit grant making organization dedicated to advancing the work of practicing physicians and to improving the quality of healthcare for all Americans
● Founded in 2003 through settlement of a class action law suit brought by physicians and state medical associations against third‐party payers
● Board of Directors: physicians and medical society leaders across the United States
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The Physicians Foundation
● 2014 Biennial Survey
• Every other national survey of physicians conducted
• Provide a “state of the union of the medical profession”
• Survey sent to over 650,000 physicians 80% of all physicians currently involved in patient care
● Standard of care → legal responsibility• Determining legal responsibility required of individual physician treating
for a unique patient is a problem in medical malpractice allegations
● Each state has its own legal definition
● General requirement:• Each physician has a non‐delegable duty to render professional services
consistent with that objectively ascertained minimally acceptable level of competence he may be expected to apply given the qualifications and level of expertise he holds himself out as possessing and given the circumstances of the particular case
41Barry Furrow et al. Liability and Quality Issues in Health Care 291 (6th ed. 2008)
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Standard of Care & the Expert Witness
● Knowledge & skills required to practice medicine lie outside realm of common knowledge
• Expert witness required
● Testify as to the standard of care
● Testify whether physician’s failure to meet that standard caused patient’s injury
● Our legal system requires experts be obtained by plaintiff & defendant NOT by the judge or jury
● Conflict of interest: Between expert’s opinion and interests of individual or entity who retained the expert
● Additional issues:
• Multiple treatment options available
• Questions in medicine not answered by scientific evidence
• “Art” remains critical along with science
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Clinical Practice Guidelines Evidence Based Medicine
● Institute of Medicine (IOM)
● EBM Defined:
“The conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.”
Sacket, D. et al. 312 Brit. Med. J. 71 (1996)
Eddy, D. 26 J. Health Pol., Policy & L. 387 (2001) 44
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Clinical Practice Guidelines
Institute of Medicine, TO ERR IS HUMAN: BUILDING A SAFER HEALTH CARE SYSTEM (1999)
Barry Furrow, et al., HEALTH LAW 267 (2nd ed. 2000)
Finder, J. Health Matrix: Journal of Law-Medicine 2000;10:67-115
● IOM
● CPGs Defined:
“Systematically developed statements to assist the practitioner with patient decisions about appropriate health care for specific clinical circumstances.”
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Clinical Practice Guidelines
● ISSUE:• Can CPGs obviate the need for expert witnesses in medical malpractice
cases and for other situations?
● Purpose of CPGs• Improve effectiveness & efficiency of medial practice
• Standardize practice
• Improve healthcare outcomes
● CPGs produced by professional societies, healthcare organizations, government, international organizations
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Clinical Practice Guidelines
● Published in 1970s & 1980s
● 1990s showed significant increase in CPGs
● NIH database → 6,793 English language CPGs
• 2011
● Variations in scientific validity, reliability, and usability exist across the world
• “standardization of the standards” has been advocated
• Assessment of patient health outcomes & functional status of patients
• Assessment of continuity & coordination of care & care transitions
• Assessment of efficiency
• Assessment of patient experience & patient, caregiver, & family engagement
• Assessment of safety, effectiveness, & timeliness of care
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Example: CPG v. Reality
• CRC Screening Recommendations
• Cancer prevention tests should be offered first. The preferred CRC prevention test is colonoscopy every 10 years, beginning at age 50.
• Screening should begin at 45 years in African Americans.
• REALITY CHECK → insurance coverage
• Despite PPACA
Rex DK, et al. Am J Gastroenterol 2009;104:739-750.
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Example: Quality Indicators for Colonoscopy
1. Appropriate indication
2. Informed consent is obtained, including specific discussion of risks associated with colonoscopy
3. Use of recommended post polypectomy and post cancer resection surveillance intervals
4. Use of recommended ulcerative colitis/Crohn’s disease surveillance intervals
5. Documentation in the procedure note of the quality of the preparation
6. Cecal intubation rates (visualization of the cecum by notation of landmarks and photo documentation of landmarks should be present in every procedure)
7. Detection of adenomas in asymptomatic individuals (screening)
8.Withdrawal time: mean withdrawal time should be >6 minutes in colonoscopies with normal results performed in patients with intact anatomy
9. Biopsy specimens obtained in patients with chronic diarrhea
10. Number and distribution of biopsy samples in ulcerative colitis and Crohn’s colitis surveillance.
11. Mucosally based pedunculated polyps and sessile polyps < 2 cm in size should be endoscopically resected or documentation of unresectabiltiy obtained
12. Incidence of perforation by procedure type (all indications vs screening) is measured
13. Incidence of post polypectomy bleeding is measured
14. Post polypectomy bleeding managed non‐operatively
Rex DK, et al. Am J Gastroenterol 2006;101:873–885.
● Government Accountability Office (GAO)• “…beneficiaries…who receive healthcare from providers who adhere to
PPACA…may receive higher quality of care…Conversely, those who receive care from providers who fail to do so may receive lower quality of care.”
• “…it is possible that, if these (PPACA) standards and guidelines become accepted medical practice, they could impact the standard of care against which provider conduct is assessed in medical malpractice litigation.”
● Government Accountability Office (GAO)• “…beneficiaries…who receive healthcare from providers who adhere to
PPACA…may receive higher quality of care…Conversely, those who receive care from providers who fail to do so may receive lower quality of care.…it is possible that, if these (PPACA) standards and guidelines become accepted medical practice, they could impact the standard of care against which provider conduct is assessed in medical malpractice litigation.”
86www.gao.gov/assests/590/589657.pdf
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Preventing Never Events
● §5001(c) of the Deficit Reduction Act of 2005 (DRA)
• Never events are not reimbursable by CMS
• Hospital Acquired Conditions (HAC’S) not reimbursable