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More Care Is Not Better; Database Provides
Benchmarking for Highly Efficient Care Survey: Vast Majority of Stakeholders Happy
with QIO Assistance Medicare Posts Hospital Payment Information
Online AHQA Supports Proposed Rule to Change Hospital
Discharge Process McClellan Issues Warning on Protection of
Beneficiary Data Commonwealth
Fund Holds Forum to Discuss Cultural Competency Newly released data from the Dartmouth Atlas Project at the Center for
the Evaluative Clinical Sciences (CECS) at Dartmouth Medical School indicates
that providing chronically ill Medicare beneficiaries more care at a
higher cost does not translate into higher quality care. To the contrary,
the study shows that beneficiaries in high-utilization areas end up with
lower quality of care. The study The study
authors say that “extra spending, resources, physician
visits, hospitalizations and diagnostic tests provided in high spending
states, regions, and hospitals does not buy longer life or better quality
of life.” In fact, the opposite is true. Benchmarking highly efficient care The study is based on records of more than 4.7 million beneficiaries
who died from 2000 to 2003 and had at least one of 12 chronic illnesses,
including: solid tumor cancers, lymphomas and leukemia, chronic pulmonary
disease, coronary artery disease, congestive heart failure, peripheral
vascular disease, severe chronic liver disease, diabetes with end organ
damage, chronic renal failure, nutritional deficiencies, dementia, and
functional impairment. Using three health care regions identified as highly efficient as benchmarks
(Salt Lake City, Utah, served primarily by Intermountain Healthcare;
Rochester, Minnesota, served largely by the Mayo Clinic; and Portland,
Ore., the largest and most metropolitan region in a state that has made
improvement in end of life care a public policy goal), researchers used
the database to compare care provided in all other regions of the country.
Highly efficient health care was defined as high-quality/low-cost. Researchers
determined that Medicare could save an estimated $40 billion – or
nearly one-third of what is already spent on chronically ill Medicare
beneficiaries – if all U.S. hospitals practiced at the high-quality/low-cost
standard set by the Salt Lake City region. By the Mayo Clinic benchmark,
savings would have been $19 billion; by the Portland benchmark, $38 billion. Barriers to Progress Another
important barrier: the absence of recognized evidence-based guidelines
for when to hospitalize, admit to intensive care, refer to medical
specialists or, for most conditions, when to order diagnostic or imaging
tests, for patients at given stages of a chronic illness. Even among
academic medical centers the authors found no consensus on the clinically
appropriate way to manage chronic illness. For instance, the database
showed that Medicare enrollees who were patients of the New York University
Medical Center had an average of 76.2 physician visits during their
last six months of life, almost one-third more than patients at the
next-highest rated (according to US News & World Report rankings)
academic medical center, the Robert Wood Johnson University Hospital
(57.7 visits per decedent). Policy Implications The findings
support fundamental changes in health care delivery to create integrated
community-based systems of care for managing chronic illness. “The problem is waste, and over-use in high rate states,
regions and hospitals — not under-use and health care rationing
in low rate areas and institutions,” the authors concluded. Read the
study: http://www.dartmouthatlas.org/atlases/2006_Chronic_Care_Atlas.pdf The Centers
for Medicare & Medicaid Services recently released
the results of its baseline survey to gauge stakeholder satisfaction
with QIO interactions. Results indicate that stakeholders are happy with
the assistance offered – more than three quarters “strongly
agreed” that “providers were providing better care because
of the QIO.” AHQA Executive
Vice President David Schulke commented, “It’s
difficult to get a more meaningful endorsement than from those at the
front lines of the struggle to improve health care quality. With increasing
pressure on health care workers to measure and improve their performance,
they just don’t have time to waste on unproductive meetings, projects,
and phone calls. So it’s significant that when they were asked
about the value of working with the QIOs, 91 percent of respondents agreed
that the information and assistance from the QIO ‘was worth the
time and effort’ and three quarters said they ‘are making
greater progress because of the QIOs.’” The survey data were developed by an independent party, Westat, under
contract to CMS. Westat interviewed a group of over 1,200 small, medium,
and large stakeholders which was about evenly split between those identified
by CMS and those recommended by QIOs. The baseline survey was conducted
between January and February of 2006 with a response rate of 82.3%. A
remeasurement survey will be conducted between June and July of 2007
and results will be part of the overall QIO evaluation, expected in November
2007. The stakeholder baseline questionnaire covered four major topic areas: Other significant findings in the report include: State-level
data from the survey will be released soon, according to CMS. The Department
of Health and Human Services (HHS) recently announced the online posting
of hospital payment information for 30 common elective procedures such
as heart surgery, hip and knee replacements, and gallbladder operations
as well as non-surgical admissions. The effort, said Centers for Medicare & Medicaid Services (CMS) Administrator Mark McClellan,
MD, PhD will help people “make better decisions on their care.” Available at: http://www.cms.hhs.gov/HealthCareConInit/01_Overview.asp#TopOfPage,
the new information shows the range of payments by county and the number
of cases treated at each hospital for a variety of treatments provided
to seniors and people with disabilities in fiscal year 2005. This new
online information is part of an overall HHS effort to make data publicly
available to all Americans as part of the Administration’s
commitment to make health care more affordable and accessible. “In
all areas of care -- hospitals, physicians, nursing homes, health plans,
and prescription drugs -- we are supporting collaborative efforts that
are providing unprecedented information to help people get the best quality
care for the best price,” said Dr. McClellan. In April 2005, quality measures on hospitals across the nation were
made available to the public through Hospital Compare (www.HospitalCompare.hhs.gov),
supported by the Hospital Quality Alliance (AQA). In addition to the
17 clinical quality measures available now, the hospital information
will be expanded to include information on patient satisfaction and outcomes
in the coming year. CMS plans to post payment information for common elective procedures
for ambulatory surgery centers later this summer, and common hospital
outpatient and physician services this fall. “People
need to know how much their health care costs. They need to know the
quality of the care they receive. And they need to have a reason to
care,” said HHS Secretary Michael Leavitt. “As
we give consumers better information on how their health care dollars
are spent, they will demand more value for their money, and the result
will be better treatment at lower costs. Earlier
this week, AHQA sent comments in support of the Centers for Medicare & Medicaid Services’ (CMS)
proposed rule regarding notification procedures for hospital discharges
of Medicare beneficiaries. Summarizing
the comment letter, David Schulke, AHQA Executive Vice President said, “AHQA supports CMS’ goal of instituting a uniform process
for hospital discharge notification consistent with procedures consumers
have learned to expect in skilled nursing facilities, home health agencies,
hospice providers and comprehensive outpatient rehabilitation facilities.” QIOs,
he noted, play a significant role in making sure that when a beneficiary
receives a hospital discharge notice. They provide timely review to determine
the discharge’s appropriateness, guard against inappropriately
early discharge, and ensure the beneficiary understands his or her rights
for appeal. Currently,
hospitals are required to deliver a single notice only when the beneficiary
disagrees with a decision to discharge. “We believe
requiring hospitals to now issue a standard notice, delivered at least
one day prior to discharge will provide the beneficiary with time needed
to make a decision regarding exercising their appeal right,” wrote
Schulke. It is “absolutely the right thing to do for beneficiaries,
and wholly consistent with the spirit of reforms enacted by Congress
twenty years ago,” he continued. According to the comment letter, if the change goes into effect it is
reasonable to expect that more informed beneficiaries will exercise their
rights and QIOs will see an increase in the number of appeal requests. Schulke
noted that implementation of the new process could result in increased
review and administrative costs for both hospitals and QIOs. To ensure
a smooth transition, he said, CMS should make certain the policy is “matched
by allocation of QIO program resources to cover the cost of any increase
in the numbers of appeals, as well as providing coverage for appeal
requests that may come in on weekends or holidays.” CMS Administrator, Mark McClellan, MD, PhD, issued a statement reminding
agency employees, contractors, and health plans that strict security
measures regarding the personally identifiable information of Medicare
beneficiaries must be maintained. Dr. McClellan’s
warning stems from an incident where health information from approximately
17,000 Medicare beneficiaries insured with Humana Health Plans, Inc.
was left unsecured in a hotel computer. In an unrelated event, an additional
approximately 250 paper applications for the health plan were stolen
from the vehicle of an independent sales agent. CMS is
requiring Humana to implement corrective actions, including: contacting
all affected beneficiaries, providing free access to a credit monitoring
service for one year, and submitting a comprehensive corrective action
plan to ensure that such privacy violations do not occur again. Dr.
McClellan said that CMS will closely monitor Humana’s activities
to ensure the plan is followed. In a press
release, Humana said it “believes the potential exposure
of personal information from these unfortunate incidents is very limited.” “ We will take aggressive actions against any plan or Medicare
contractor that compromises the privacy and security of Medicare beneficiaries’ personal
information,” warned Dr. McClellan. In May,
The Commonwealth Fund brought together researchers, providers, policymakers,
advocates, and other stakeholders to discuss the future of cultural
competency research, practice, and measurement. Materials from “Cultural Competency: Understanding the Present and Setting
Future Directions,” are now available online. In addition to an introduction by Underserved Program Director Anne
Beal, M.D, audio, slides, and a transcript from the meeting are available.
Materials from the following presentations are included: Papers based on these presentations are planned over the next year. View the materials online at: http://www.cmwf.org/topics/topics_show.htm?doc_id=373785&#doc373785  Home :: Inside AHQA :: For The Media :: Public Policy :: Advancing Quality :: Quality Connections :: SiteMap
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