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Journal Article Shows Vast Improvement in Pressure Ulcers; CMS, AHCA, and AHQA Promote Findings CMS Proposes Moving HPMP Work to RACs and MACs HHS Demo Project Pays Docs to Implement and Use EHRs National and State Medical Groups Oppose S. 1947 Secretary Leavitt Explains Value Exchanges to AHRQ Conference Attendees Medicare Updates Web Site to Help Beneficiaries During Open Enrollment Group Urges Mandated e-Prescribing in Medicare AHRQ Data Show that Five Percent of Those Who Contract MRSA Die Health IT Bill Aims to Coordinate Efforts, Accelerate Adoption McKesson Adds Free Advanced Training for InterQual Users Milliman Care Guidelines Releases New Behavioral Health Guidelines Product CMS Names States, Measures for Home Health Demo AHRQ-Sponsored Supplement Focuses on Comparative Effectiveness eHI Seeks Support for New Learning Laboratory Medicaid Quality, Efficiency Projects Get Federal Funding In a national collaborative project, nursing homes working with QIOs successfully reduced the incidence of the most serious bed sores by 69 percent in one year, according to findings of the study, “Collaborative Clinical Quality Improvement for Pressure Ulcers in Nursing Homes,” which was published in the October edition of the Journal of the American Geriatrics Society. AHQA coordinated outreach efforts regarding the study with the Centers for Medicare & Medicaid Services and the American Health Care Association (AHCA), a national association representing the nursing home industry. “This recent study published in the respected Journal of the American Geriatrics Society reaffirms that collaborative efforts between nursing homes, QIOs and the federal government are effective in improving the care and patient outcomes for our nation’s most vulnerable populations,” stated Bruce Yarwood, president and CEO of AHCA in a press release. In the pilot project, which began in 2003, 52 nursing homes in 39 states voluntarily worked with experts from QIOs to improve pressure ulcer care. Thirty-five nursing homes reported data monthly over one year. After comparing data from the first three months and the last three months, the authors found that the incidence of Stage III and IV facility-acquired pressure ulcers, the most dangerous kind, was reduced by 69 percent. Little effect was seen in Stage I-II pressure ulcers. Despite major improvement in the worst types of pressure ulcers, the publicly reported measure did not reflect any improvement at all. The authors determined that the public measure was flawed because it bundled minor and major pressure sores together, thus obscuring actual progress in the care that patients are experiencing in nursing homes. So they recommended revising the way improvement in pressure ulcers is measured so that it would better reflect the care experienced by patients. In a press release, AHCA’s Yarwood encouraged CMS to swiftly adopt the study’s recommendation, “by updating the publicly reported measure for pressure ulcers in nursing home residents to reflect more accurate information, it will help consumers better assess the care provided in our nation’s long term care facilities.” “This is a remarkable gain in a large number of facilities, against a condition that is as devastating and costly as it has been resistant to improvement,” said Kerry Weems, CMS’ Acting Administrator. “In this case, the work of Medicare’s Quality Improvement Organizations (QIOs) has helped us refocus our research and change our data collection and public reporting so that CMS can do a better job informing residents, family members, and the nursing homes themselves about nursing home quality.” Barry M. Straube, MD, Director of the Office of Clinical Standards and Quality echoed those sentiments and suggested that the agency might adopt the author’s recommendations. “The results will enable us to separate the serious pressure ulcers from the superficial ones, a change that will help beneficiaries and their families to see whether a nursing home has implemented the best practices available,” he said in a press release. At the Quality Net meeting last week, CMS officials explained that current plans call for QIOs to work on two pressure ulcer measures, stage I and II in hospitals and stage II and IV in nursing homes. Some QIOs involved in the study collaborated with hospitals and other providers outside the nursing home setting, a critical step for timely and improved care since some patients start to develop pressure ulcers before they enter a nursing home. “We expect that the results of this study will inform the upcoming Scope of Work, which focuses more on cross-cutting tasks,” said David Schulke, AHQA Executive Vice President. “Such action would seem to support the agency’s effort to use interventions that are based on sound science.” “Reducing pressure ulcers—the clinical term for bed sores—is a priority for CMS and quality improvement organizations (QIOs) nationwide,” said Kerry Weems, acting administrator of CMS. “It is also one of the most important goals of the voluntary Advancing Excellence in America’s Nursing Homes campaign, of which CMS is a founding member.” Most QIOs are serving as leaders in the national campaign, providing all nursing homes with the tools to improve. Through the campaign, QIOs are also providing assistance to nursing homes that are not directly involved with the QIO program. Authors of the study are: Joanne Lynn, MD; Jeff West, RN, MPH; Susan Hausmann, MS; David Gifford MD, MPH; Rachel Nelson, MHA; Paul McGann, SM, MD; Nancy Bergstrom, RN, PhD; and Judith Ryan, RN, PhD. AHQA, CMS, and AHCA distributed press releases on this study on October 22. At a recent conference Centers for Medicare & Medicaid Services (CMS) officials told the Quality Improvement Organization (QIO) community that it supported keeping most beneficiary protection activities within the QIO program in the proposed 9th Scope of Work. However, the Hospital Payment Monitoring Program (HPMP) work currently conducted by QIOs would be moved to Recovery Audit Contractors (RACs) and Medicare Administrative Contractors (MACs), CMS officials said. The RAC program was authorized by Congress and has been operating under a demonstration project in California, New York, and Florida. In an October 26th letter to CMS Acting Administrator Kerry Weems, the American Hospital Association (AHA) expressed its opposition to CMS’ plans to quickly expand the current RAC demonstration project to a nationwide program. AHA’s Executive Vice President Rick Pollack, wrote the letter to provide input on CMS’ plans, which he called “irresponsible” without first addressing flaws identified in the demonstration project. One such flaw that the AHA identified is the addition of medical necessity reviews to the RAC Scope of Work. Congress did not ask RACs to conduct medical necessity reviews, as it had instructed QIOs, and did not put into place safeguards to ensure fairness of such reviews, as it did for QIOs. But CMS has directed RACs to conduct medical necessity reviews despite a lack of evidence of their ability to do so and essential safeguards. “Medical necessity reviews must be based on clinical review and are entirely inappropriate for RAC review,” the AHA wrote. This illustrates that CMS is overreaching in its administration of Congress’ intentions, the AHA said, urging CMS to “exclude all medical necessity determinations from the RAC Statement of Work.” Currently, HPMP reviews are conducted as a part of the QIO case review portfolio under the QIO Scope of Work. All monies recovered are returned to the government. Not so with the RACs, which receive a portion of the improper payments they recover from providers. AHA said that the “bounty hunter-like” RAC payment system “provides incentives to aggressively deny any claims that appear at all questionable” that “creates significant burden and requires unnecessary administrative costs for hospitals to resolve.” While recognizing that the recently released RAC Scope of Work includes a provision for RACs to return their portion of the recovered payment if an appeal discredits the original review, AHA says this change will “not fully eliminate the perverse incentives” and calls for RACs to be paid a contractual amount. “Any collections should be used to support health care services to America’s seniors and disabled, not the bottom line of RAC companies.” HHS Secretary Mike Leavitt recently announced a five-year demonstration project that will provide higher Medicare payments to small to medium-sized physician practices that adopt and use an electronic health record (EHR) system to meet certain clinical quality measures. Conducted by the Centers for Medicare & Medicaid Services (CMS), the demonstration will be open to up to 1,200 physician practices beginning in the spring. The core incentive payment to practices will be based on performance on the quality measures, with an enhanced bonus based on the how well integrated the EHR is in helping manage patient care. The EHR system must be in place by the end of the second year and it must be certified by an HHS recognized authority. The Certification Commission for Healthcare Information Technology (CCHIT) is currently the only certification body recognized by the Secretary of HHS. “Broad adoption of electronic health records has the potential not only to improve the quality of care provided, but also to transform the way medicine is practiced and delivered,” said Secretary Leavitt. Participating practices will use the EHR system to perform specific functions that can positively affect patient care processes, such as clinical documentation and ordering prescriptions. Potential benefits of broad adoption of EHRs include: “We want to revolutionize the way vital health data is managed and maintained, so we are taking steps to change from a paper-based medical record to an electronic health record,” said CMS Acting Administrator Kerry Weems. “This project will appropriately align incentives to reward doctors in small physician practices who use certified EHRs as tools to deliver higher quality care. This reward structure will bring the benefits of electronic health records to Americans at their most frequent point of contact with health care – their family doctor.” In order to amplify the effect of this demonstration project, federal officials are encouraging private insurers to offer similar incentives for EHR adoption. Secretary Leavitt also announced that HHS has begun the process of chartering Value Exchanges as part of the Value-Driven Health Care Initiative. “Efforts to improve the quality and cost of health care start with national standards, but end with local control,” Secretary Leavitt said. More than 20 QIOs are currently serving as Community Leaders (according to an AHQA Matters accounting), the first step to becoming a Chartered Value Exchange (CVE) under Secretary Leavitt’s Value Driven Health Care Initiative. CVEs will aggregate public and private data to provide consumers cost and quality information at the local health care level. Ultimately, CVEs will have access to Medicare physician quality performance measurement results that will be provided by CMS, likely as soon as the summer of 2008. “We expect numerous QIOs to apply for Chartered Value Exchange status by the end of this year, so we’re partnering with the National Business Coalition for Health to explore successful models at their meeting next week, and we’re invited coalition members to the AHQA meeting in February,” said David Schulke, AHQA Executive Vice President. More information about certification is available at: www.hhs.gov/healthit/certification/background/. More information about CVEs is available at: http://www.hhs.gov/valuedriven/communities/valueexchanges/exchanges.html. In an October 25th letter, the American Medical Association (AMA) joined 38 other national medical associations and 47 state medical societies in expressing opposition to elements of the “Continuing the Advancement of Quality Improvement Act of 2007” (S. 1947), which was introduced by Senators Charles Grassley (R-IA) and Max Baucus (D-MT) in early August. Earlier this year the AMA resolved to support the continuation of case review as a part of the QIO contract and to oppose changes in QIO governance structures that would place physicians in the minority on QIO boards of directors. The CAQI Act proposes to do both. “Carving up these responsibilities and assigning important QIO duties to PROs will turn back the clock to a time when Medicare’s Peer Review Organizations responded to quality shortcomings with punitive measures, rather than assistance and education,” the signers wrote. Echoing the messages that the QIO community is bringing to Congress, the letter advocated that the “functions and structure [of QIOs] should be preserved” and that “any changes to the program involve careful thought and deliberation.” Health and Human Services Secretary Mike Leavitt delivered the keynote address at the Agency for Healthcare Research and Quality (AHRQ) Annual Meeting on September 28th where he discussed efforts to improve health care by providing more transparent information on cost and quality. AHRQ is developing a process by which it will recognize Value Exchanges and the chartering process should begin this fall said the Secretary. The first step to becoming a Chartered Value Exchange (CVE) is to be designated a Community Leader. AHRQ has already designated about 80 Community Leaders across the country; more than 20 of which are QIO-led. According to Secretary Leavitt, a CVE will use “national standards and neighborhood strategies” to improve care. “First of all, a value exchange is local—I want to underscore that word—local,” said the Secretary. “Now local could be in a community. It could be in a metropolitan area. It could be in a region, but it is not national. It is local because it’s where purchasers and plans and providers and consumers all work together to get usable information about quality that’s available to the public. And again, it is local but it uses national standards,” he continued. The Centers for Medicare & Medicaid Services will give pre-crunched numbers to the CVEs that will “provide actual ratios for specific physician groups on performance measures that have been adopted by AQA and endorsed by the National Quality Forum” so the CVEs can “see for themselves how many and how often certain groups of doctors have prescribed a certain procedure, for example,” the Secretary explained. The CVEs will couple this public data with private data obtained through a program funded by the Robert Wood Johnson Foundation. RWJF recently provided $16 million in funding to support a parallel effort to aggregate private payer data. Read a transcript of Secretary Leavitt’s speech at: http://www.ahrq.gov/news/sec92807trans.htm; video is available at: http://www.ahrq.gov/news/sec92807.htm. Read a fact sheet on Chartered Value Exchanges at: http://www.hhs.gov/news/facts/physicianperformance.html Enhancements to Medicare’s Web site, including the Medicare Prescription Drug Plan Finder, are expected to make it easier for beneficiaries to find information about their coverage as well as available drug plans, including out-of-pocket costs, pharmacy networks, and important Medicare news and updates. Open enrollment begins on November 15th and runs through October 31st. “The Plan Finder site averages more than 900,000 page views per week, and more than 4.75 million people with Medicare have enrolled in a drug plan since the program began,” said CMS Acting Administrator Kerry Weems. Now is the time for beneficiaries to prepare and compare to find the best plan that meets their needs, the agency said in a press release. Beneficiaries are urged to gather the prescription drugs they are currently using along with any Medicare, Social Security or current drug plan mailings before accessing the Web site to evaluate their current drug plan or select a new plan. People without access to the Internet can get the same information by calling 1-800 MEDICARE, visiting the local State Health Insurance Assistance Program office, or visiting an enrollment event. In partnership with local partners on the ground, Medicare representatives are helping to educate beneficiaries about the tools and resources available during open enrollment and help them choose a plan through the “Working Together for Better Health” bus tour. CMS has also developed a comprehensive Web site for beneficiaries who are eligible for low-income subsidies. This site will help Medicare partners identify and counsel low-income subsidy (LIS) beneficiaries throughout the open enrollment period. The site also includes an annual LIS Outreach Toolkit providing LIS data in both interactive maps and sortable spreadsheets. A Coalition of 22 business, consumer, and other stakeholder groups is calling on Congress to include language in upcoming Medicare legislation that would require the use of e-prescribing in Medicare to improve safety and increase savings. In an October 16th letter to congressional leaders, the Coalition “strongly encouraged” policymakers to implement a safety requirement in coming Medicare legislation that e-prescribing be used for all Part D prescriptions by 2010. The letter was sent to House Ways & Means Committee Chairman Charles Rangel (D-NY) and Ranking Member Jim McCrery (R-LA); House Energy & Commerce Committee Chairman John Dingell (D-MI) and Ranking Member Joe Barton (R-TX); and Senate Finance Committee Chairman Max Baucus (D-MT) and Ranking Member Charles Grassley (R-IA). The letter refers to a report released last year by the Institute of Medicine, which recommended that all physicians adopt e-prescribing technology by 2010. However, less than one-in-ten physicians currently use the technology, the Coalition says. In the report, Preventing Medication Errors, the IOM estimated that at least 1.5 million adverse drug events happen every year but that e-prescribing could be an important step toward reducing that number, which could reduce costs and improve safety. “By writing prescriptions electronically, doctors and other providers can avoid many of the mistakes that accompany handwritten prescriptions, as the software ensures that all the necessary information is filled out—and legible. Furthermore, by tying e-prescriptions in with the patient’s medical history, it is possible to check automatically for such things as drug allergies, drug-drug interactions, and overly high doses. In addition, once an e-prescription is in the system, it will follow the patient from the hospital to the doctor’s office or from the nursing home to the pharmacy, avoiding many of the “hand-off errors” common today,” according to an IOM summary of the report’s findings. The Coalition is proposing that the requirement to adopt e-prescribing technology for all Part D prescriptions be “combined with annual incentives for participating physicians equal to 1 percent of their allowed Medicare payments.” The Coalition contends that the move will “save billions, even after providing physicians with funds for equipment and training.” A copy of the letter is available on the Pharmaceutical Care Management Association Web site: pcmanet.org. One out of every 20 patients treated in U. S. hospitals for Methicillin-resistant staphylococcus aureus, or MRSA, in 2005 died from the infection. Most of the patients who died were elderly or low income. The death rate for hospitalized MRSA patients was higher than the 4 percent death rate for hospitalized tuberculosis patients, another potentially deadly illness. AHRQ also found that: This AHRQ News & Numbers summary is based on data in Infections with Methicillin-Resistant Staphylococcus Aureus (MRSA) in U.S. Hospitals, 1993-2005, Statistical Brief No. 35 (http://www.hcup-us.ahrq.gov/reports/statbriefs/sb35.pdf). The report uses statistics from the Nationwide Inpatient Sample, a database of hospital inpatient stays that is nationally representative of inpatient stays in all short-term, non-Federal hospitals. The data are drawn from hospitals that comprise 90 percent of all discharges in the United States and include all patients, regardless of insurance type, as well as the uninsured. According to CMS officials, the QIO program might focus quality improvement efforts on MRSA in the upcoming 9th Scope of Work, which is scheduled to begin in August of 2008. A new health information technology (HIT) bill designed to accelerate the adoption of health information technology and increase the efficiency and effectiveness of the U.S. health care system was introduced in the House of Representatives on October 10th. The Promotion of Health Information Technology (HIT) Act, H.R. 3800, introduced by Congresswoman Anna G. Eshoo, (D-CA), intends to streamline adoption of HIT interoperability standards and require the federal government to abide by those standards. It also authorizes funding to promote HIT adoption nationwide. H.R. 3800 is co-sponsored by Mike Rogers (R-MI). “Health information technology (HIT) promises to revolutionize the health care delivery system and have a powerful effect on enhancing patient safety, reducing medical errors, improving the quality of care, and reducing health care costs,” said Rep. Eshoo in a statement. Eshoo is a member of the House Energy & Commerce Subcommittee on Health, co-chairs the House Medical Technology Caucus, and serves as Vice Chair of the 21st Century Health Care Caucus. McKesson will offer an in-depth course for seasoned users of InterQual starting this month. Like the annual web-based training for InterQual users, the InterQual Certified Instructor (IQCI) Training is designed for staff in your Medicare lines of business and is provided at no cost to QIOs. The IQCI program provides comprehensive training with a focus on enabling participants to train others within their own organizations. Those who meet the certification requirements and complete the instructor program will receive the IQCI credential and a continuing education certificate. The offering exemplifies McKesson’s ongoing commitment to developing high quality educators and training programs for its industry-leading criteria. McKesson continues to offer InterQual web-based training sessions for beginning users. Half-day sessions are planned for Acute Level of Care, Long-Term Acute Care (LTAC), Procedures, and Behavioral Health Criteria (Adult, Chemical Dependency / Dual Diagnosis, Geriatric and Residential). Each session, led by a McKesson Product Education Specialist, covers concepts related to the criteria as well as the review process. Web-based trainings are scheduled to begin November 19 and run through early December. To sign up for a web program or schedule an IQCI session, please contact InterQual.Training@McKesson.com. Milliman Care Guidelines released the Behavioral Health Guidelines in September, the seventh product in its series of evidence-based clinical guidelines that are available through a wide variety of software options. The Behavioral Health Guidelines are an evidence-based decision support resource covering five levels of care: inpatient, residential, partial hospital programs, intensive outpatient programs, and acute outpatient care. These guidelines address indications for use at each level of care and the appropriateness of specific psychological, behavioral, and pharmacologic therapies. Tools and criteria are provided that can aid in developing outpatient alternatives to higher levels of care, facilitate the progress of patients whose recovery is delayed, and develop comprehensive plans for transition from one level of care to another. The fifteen guideline groups cover the full spectrum of mental health and substance abuse diagnoses. For more information, call 888.464.4746 or visit www.careguidelines.com. The Centers for Medicare & Medicaid Services (CMS) recently announced plans for a home health pay-for-performance demonstration that is set to begin January 1, 2008; recruitment of agencies for the project will begin later this fall. As part of the demonstration, home health agencies that perform at the highest level or improve most significantly on quality improvement efforts will be eligible for incentive payments. Home health agencies will not have to submit additional data to participate – data from seven quality measures already in use will be used to evaluate performance (based on Outcome-Based Quality Improvement data). The measures are: Because improvements in home health care result in savings in other areas of care, the incentive payments for this demonstration will be based on overall savings to the Medicare program. No participating home health agency will face a payment reduction based on their participation in the demonstration project. Participating agencies will be randomly assigned to either a study group or a control group. Those agencies assigned to the study group will have their patients’ outcomes monitored over time. Those agencies with the best patient outcomes among participants in their states, or with the highest degree of improvement relative to the previous year, will be eligible for incentive payments. The demonstration will run for two years in the following seven states: Connecticut, Massachusetts, Alabama, Georgia, Tennessee, Illinois, and California. Additional information about the demonstration can be found at: A supplement to the October 2007 issue of Medical Care, “Emerging Methods in Comparative Effectiveness and Safety,” includes 23 articles from a national collection of Agency for Research and Quality (AHRQ) – funded researchers. The articles address such issues as methodologic challenges to studying patient safety and using Medicaid claims data to study drug use. The supplement is sponsored by AHRQ through the Effective Health Care program’s DEcIDE Network, which supports accelerated practical studies on comparative effectiveness and safety. Read the supplement at: eHI is now reaching out to engage supporters for its next set of learning laboratories, which will focus on testing and evaluating the impact of consumer access to clinical information on existing or new chronic care or disease management efforts through a health information exchange. The work will be overseen by a National Advisory Board made up of a diverse set of health care stakeholders. State and regionally-based collaborative efforts will compete for awards which will be selected based upon an independent evaluation. Findings and tools developed under this new collaborative will be placed in the public domain. Organizations interested in sponsoring this project should contact eHI’s CEO, janet.marchibroda@ehealthinitiative.org. The Agency for Healthcare Research and Quality (AHRQ) recently awarded $41.6 million to fund and expand the Centers for Education and Research on Therapeutics (CERTs), including a new coordinating center. The CERT program includes 14 centers that form a national infrastructure to conduct research to build a strong evidence base that can educate providers on the most appropriate, effective, and efficient therapeutics in order to improve the quality of health care and reduce costs. The four new centers join six originally-funded centers and four other centers that received funding in 2006. The four new centers are: The funding also provides for a new coordination center, Kaiser Permanente’s Center for Health Research in Portland, Oregon. The Kaiser center will assume infrastructure and leadership support for the CERTs National Steering Committee and research centers. It will also help expand the effort of translating CERT research findings into practice through collaboration with others. The ten existing centers include: Duke University (therapies for disorders of the heart and blood vessels); Harvard Pilgrim Health Care on behalf of the HMO Research Network (drug use, safety, and effectiveness in defined populations cared for by health plans); University of Alabama at Birmingham (therapies for disorders of the joints and bones); The Arizona CERT at The Critical Path Institute (potentially harmful drug interactions, particularly in women); University of Pennsylvania (therapies for infectious diseases); and Vanderbilt University (prescription drug use in a Medicaid population); MD Anderson, Texas (risk and health communication; patient, consumer, and professional education); Rutgers, The State University of New Jersey (mental health therapies); the University of Iowa (improving elderly care, both therapeutics and care management); and the Weill Medical College of Cornell University, New York (therapeutic medical devices). AHQA EVP David Schulke serves as a public member of the CERTs Steering Committee. Sixteen states and Puerto Rico were recently awarded nearly $52 million in unmatched federal funds for projects that will improve Medicaid efficiency, economy, and quality of care. These awards are the second round of “transformation grants” that are part of a total $150 million approved by Congress under the Deficit Reduction Act of 2005. In the first round, 26 states received $98 million distributed last January. “These transformation grants express the core goal of this Administration to give states the kind of flexibility they need to deliver high quality care in an efficient and more economical way,” Secretary Leavitt said. States that received funding are working on projects including: health care transparency, using e-prescribing, improving patient outcomes, public reporting, electronic health records, risk management, fraud and abuse detection. More information on the grants can be found at: www.cms.hhs.gov/MedicaidTransGrants.  Home :: Inside AHQA :: For The Media :: Public Policy :: Advancing Quality :: Quality Connections :: SiteMap
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