Checklist for Best Practice Included in New
AHRQ, CMS Registries Handbook
Roundtable Discussion Highlights Value Driven
Health Care Progress
Rep. Stark Seeks Greater Efficiency, Quality
in Medicare
Members of Congress Support National Health
IT Week
CMS Issues Money-Follows-the-Person Grants
AHQA Supports Rockefeller, Kennedy, Snowe
S-CHIP Bill
Study Shows QIO Work in Nursing Homes Is ‘Sound
Investment’
Call for Papers: AHRQ-Sponsored Health Services
Research Theme Issue
CAHPS LTC Survey Available
Special Open Door Forum on Registry-based Reporting for PQRI
Checklist for Best Practice
Included in New AHRQ, CMS Registries Handbook
The Agency for Healthcare Research and Quality (AHRQ) recently released
a new handbook to help researchers and others use patient registries
to evaluate the real-life impact of health care treatments.
The new 219-page guide, “Registries for Evaluating Patient Outcomes:
A User’s Guide,” identifies the best scientific practices
for operating registries. Covered topics include: how registries should
be designed, what types of data sources may be accessed, and how to encourage
participation among patients and health care providers. Also included
are chapters on detecting adverse events, interpretation of data, and
how to handle issues related to ethics and publication of research papers.
The handbook’s summary chapter serves as a checklist for best practices.
Unlike randomized clinical trials, which study patients under strict
eligibility and treatment protocols, patient registries document the
experiences of patients in everyday clinical practice. Observing those
patients’ responses to treatment can provide important insights
into which health care strategies work best in actual practice. One of
the nation’s best-known registries is the Surveillance Epidemiology
and End Results (SEER) Program, which is managed by the National Cancer
Institute.
Development of the handbook was co-funded by AHRQ and the Centers for
Medicare & Medicaid Services. Thirty-nine contributors from industry,
academia, and government collaborated to create the handbook.
“This new reference will be a tremendous resource to researchers,
patient groups, health insurers, pharmaceutical companies, and others
who are eager to investigate which treatments work best,” said
AHRQ Director Carolyn M. Clancy, MD. “Databases that depict outcomes
in patient populations over time carry great potential for advancing
the quality, safety, and effectiveness of health care.”
The guide is downloadable at: http://www.effectivehealthcare.ahrq.gov,
and soon will be available in two printed forms—as the full-length
document and as a 13-page summary that includes the best practices checklist.
Copies may be ordered from the AHRQ Publications Clearinghouse by sending
an E-mail to ahrqpubs@ahrq.gov or
calling 1-800-358-9295.
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Roundtable Discussion Highlights
Value Driven Health Care Progress
Secretary of Health and Human Services Michael Leavitt recently praised
American employers, health care providers, and health plans for coming
together to support the four cornerstones of his value-driven health
care initiative.
“Consumers have extensive information to help them make good choices
when they buy cars or get mortgages,” Secretary Leavitt said. “But
when it comes to choices about their health care, little information
about quality or cost has been available. The purpose of the Value-Driven
Health Care movement is to make that information available, and then
reward people for using it.”
In his opening remarks Secretary Leavitt likened the health care to
the airline industry saying that it was time for health care to shift
from being a sector to system. “Government ought not be the
proprietor, but the organizer of health care,” he said.
Secretary Leavitt reported that the federal government; half of the
states; about 775 employers, including almost half of the top 200 U.S.
corporations; and numerous unions, communities, doctors and hospitals
have joined the movement. Many QIOs have also signed on to support
the effort and representatives from QIOs in Connecticut, Illinois, Iowa,
Alabama, New Jersey, New York, Ohio and Wisconsin attended the event.
Al Hubbard, who serves as Assistant to the President for Economic Policy,
and Director of the National Economic Council, commended Secretary Leavitt’s
efforts to get this initiative off the ground. Hubbard said that
President Bush believes that the country is “close to a tipping
point” on health care and “very, very much appreciates what
everyone here is doing.”
Roundtable participants from the purchaser, provider, and health plan
communities addressed a range of topics and discussed efforts they are
undertaking to support the Secretary’s agenda. Issues included
the need to work collaboratively at the local level, improving care through
better prevention, payment reform to provide incentives for appropriate
care rather than more care, fragmentation of the health care system,
employer-sponsored EHRs, and consumer education on cost and quality data.
More information on Value-Driven Health Care is available at www.hhs.gov/valuedriven.
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Rep. Stark Seeks Greater
Efficiency, Quality in Medicare
At a Ways & Means Health Subcommittee hearing, Herb Kuhn, Acting
Deputy Administrator for the Centers for Medicare & Medicaid Services,
testified that CMS has the capacity to begin profiling physicians.
In announcing the hearing, subcommittee chairman Pete Stark (D-CA) said
that its purpose was to “ensure that Medicare resources are being
used efficiently and effectively to achieve high quality outcomes.” Chairman
Stark noted that it was incumbent upon his subcommittee to investigate
ways to make Medicare more efficient, particularly in light of an expected
$60 billion expense for physician services in 2007 and a growing body
of research showing significant geographic variation in care utilization
that is unrelated to health outcomes.
Two of the methods to increase efficiency discussed at the hearing were
physician profiling and payment bundling.
Physician Profiling
Physician profiling includes developing individual utilization data by
physician and comparing billing patterns to other physicians across
a geographic region and doing something with the resulting data. Uses
of the resulting profiles could include anything from providing feedback
to individual physicians, working with physicians to increase efficiency,
or public reporting of compiled data.
Payment Bundling
In addition to discussion about detailing physician clinical practice
patterns and resource use, witnesses at the hearing focused on the
potential of bundling physician payment based on episodes of care. Robert
Berenson, MD, Senior Fellow at the Urban Institute explained that payment
bundling makes sense and is already being used for surgical procedures
and end stage renal disease treatment. Lessons learned from these
successful examples, he said, could be used to tweak and expand bundling
to other areas of practice – particularly chronic disease, “in
my opinion there is little question that bundling payments for episodes
of care needs to be a primary objective of physician payment reform,
just as it has been successful when applied to other providers in Medicare.”
Medical Home
The Medical Home concept, which allows primary care physicians to be
reimbursed for care coordination not simply a la carte treatment, is
another example of a way to bundle physician services, said Dr. Berenson.
Not only is the Medical Home “conceptually right thing to do” it
also provides “practices with improved incentives to avoid unnecessary
downstream utilization by other providers.” The Medical
Home could be particularly effective for treating chronically ill patients
such as those with diabetes or heart disease who require more consistent
care.
The American Academy of Family Physicians and other primary care organizations
support the notion of a Medical Home, said Rick Kellerman, MD, AAFP President.
The current payment system, he said, “provides no incentive for
physicians to coordinate the tests, procedures, or patient health care
generally and it puts very little emphasis on preventive services and
health maintenance” which has “produced an expensive, fragmented
Medicare program.” AAFP recommended that beginning
in 2008, Medicare compensate physicians for care coordination services.
Other witnesses at the hearing included:
- Bruce Steinwald, Director, Health Care, Government Accountability
Office
- Glenn M. Hackbarth, Chairman, Medicare Payment Advisory Commission
- Anmol S. Mahal, M.D., President, California Medical Association,
Freemont, CA
- John E. Mayer, Jr., M.D President, Society of Thoracic Surgeons
Witness transcripts and other details on the hearing are available at:
http://waysandmeans.house.gov/hearings.asp?formmode=detail&hearing=558&comm=1
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Members of Congress Support
National Health IT Week
Stabenow, Snowe Introduce HealthTech Act
Health care stakeholders from across the nation convened in Washington,
DC, recently to participate in National Health IT Week 2007, culminating
in a press conference where Members of Congress joined health care leaders
in calling for greater national emphasis on health IT to transform American
health care.
National Health IT Week is a collaborative forum that enables private
industry and the public sector to strengthen relations in pursuit of
President Bush’s goal of widespread health IT adoption by 2014. It
consists of individually planned and hosted conferences and meetings
that each work to elevate national attention on the necessity of health
IT adoption.
“A full 60 organizations speaking with one voice to Congress on
this issue reinforces the critical need for health IT implementation
across the board -- from the largest hospitals to the smallest physician
practices – to ensure high quality, efficient, equitable, and
timely care,” said David Schulke, AHQA Executive Vice President.
AHQA is a Health IT Week partner.
“National Health IT week is an important opportunity to highlight
technology that has the ability to lower costs while improving quality
of care,” said Senator Debbie Stabenow (D-MI).
At the press conference, Senator Stabenow announced that she and Senator
Olympia Snowe (R-ME) had introduced the Health Information Technology
Act of 2007, or HealthTech Act, which aims to give tax incentives and
resources to offset the costs of investing in new health information
technology.
S. 1408 would establish a 5-year, $4 billion competitive grant program
for the information technologies and services needed by health care providers
such as hospitals, physicians, skilled nursing facilities, community
health centers, and community mental health centers. At least 20 percent
of the funds would be available to rural areas or regions with a shortage
of health care professionals.
“The result of using 19th century technology in a 21st century
health care system is higher costs, increased errors and decreased quality
of care,” said Stabenow. “It’s long past time that
we fully utilize technology to make health care accessible and affordable
for every family and business.”
Representatives Phil Gingrey (R-GA) and Charlie Gonzalez (D-TX), both
of whom also spoke at the press conference, introduced a similar measure,
the National Health Information Incentive Act of 2007, in the House of
Representatives in April. H.R.1952 targets small physician practices
as the focus of efforts to achieve wide scale adoption of health information
technology (HIT) to increase efficiency in health care practices and
broader access to medical records.
“Widespread HIT adoption will revolutionize the standard and quality
of healthcare received in America,” said Rep. Gonzalez in a recent
press release. “These incentives attack the very root of the problem
facing small practices, where a majority of Americans receive their care,
by helping them overcome financial obstacles they face with HIT implementation.”
Rep. Gingrey, a physician, continued, “Right now, the healthcare
sector is woefully behind in using technology to reduce medical errors
and streamline care. I can go to Antarctica and get cash from an ATM
without a glitch, but should I fall ill during my travels, a hospital
there couldn’t access my medical records or know what medications
I take. Our ATMs shouldn’t be more advanced than our medical
records.”
In addition to Senator Stabenow and Representatives Gonzalez and Gingrey,
other speakers at the Health IT press conference included:
- Senator Sheldon Whitehouse (D-RI)
- Representative Patrick Kennedy (D-RI), Co-Chair of the 21st Century
Health Care Caucus
- Representative Dennis Moore (D-KS)
- Representative Tim Murphy (R-PA), Co-Chair of the 21st Century Health
Care Caucus
- David Roberts, Vice President for Government Relations of the Healthcare
Information and Management Systems Society (HIMSS)
- Hugh Zettel, Vice Chair of the Electronic Health Record Vendors Association
(EHRVA) and Director, Government and Industry Relations, GE Healthcare
- Billy Webb, Chief of Sales for Companion Technologies
- Paul Uhrig, Executive Vice President of Corporate Development and
Chief Privacy Officer, SureScripts
CMS Issues Money-Follows-the-Person
Grants
CMS Acting Administrator Leslie Norwalk recently announced that $547
million in “Money Follows the Person” (MFP) five-year grants
had been awarded to 3 states and the District of Columbia to move elderly
and disabled individuals from institutional care to community living
arrangements.
“There is more evidence than ever that people who need long-term
care prefer to remain in their own homes and communities whenever possible,” said
Ms. Norwalk. “This new program will help states shift
Medicaid’s traditional emphasis on institutional care to a system
offering greater choices that include home-based services.”
“The concept of money following the person to the most appropriate
setting improves beneficiary satisfaction while reducing Medicaid costs,” Ms.
Norwalk continued.
The “Money Follows the Person” initiative was included in
the Deficit Reduction Act of 2005 and allows CMS to provide a total of $1.75
billion over five years (2007-2011) to states. Those states receiving
grant funds will design programs to:
- Eliminate barriers that prevent Medicaid-eligible individuals from
receiving support for appropriate and necessary long-term services
in the settings of their choice;
- Increase the ability of the state Medicaid program to support an
individual’s choice to receive long term care services in the
home and community based setting; and
- Ensure that procedures are in place to provide quality assurance
and continuous quality improvement for care provided outside of the
institutional setting.
The states included in this round of grant awards include: Delaware,
Georgia, Hawaii, Illinois, Kansas, Kentucky, Louisiana, New Jersey, North
Carolina, North Dakota, Oregon, Pennsylvania, and Virginia. The
MFP grants are part of the New Freedom Initiative. More details
are at: http://www.cms.hhs.gov/newfreedom/.
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AHQA Supports Rockefeller,
Kennedy, Snowe S-CHIP Bill
In a letter to Senator Jay Rockefeller (D-WV) on May 17, AHQA expressed
its support for S. 1224, Children’s Health Insurance Program (CHIP)
Reauthorization Act of 2007, highlighting those elements that call for
improved quality in pediatric care.
Among other things, S. 1224 would enhance quality in the S-CHIP program
by requiring every state to create a “quality assessment and improvement
strategy,” add oversight of managed care S-CHIP programs where
it is lacking, developing pediatric quality measures and publishing state-based
reports based on those measures.
External quality review is not mandated in the current S-CHIP legislation. But
many states across the country do employ External Quality Review Organizations
(EQROs) for S-CHIP managed care programs; some QIOs hold these contracts. Since
not all states utilize such review, no consistent, national system of
review exists. “AHQA believes that extending these
quality assurance protections to S-CHIP will provide appropriate oversight
to managed care plans providing benefits to children,” wrote David
Schulke, AHQA Executive Vice President.
“AHQA also supports the inclusion of Sec. 601(c)(3) in S. 1224,
which requires the Secretary of Health and Human Services to consult
with QIOs, among other experts, in order to establish areas of need and
priorities for creating pediatric quality measures,” Schulke wrote.
Schulke offered the association’s support in helping Senators
Rockefeller, Kennedy, Snowe, and cosponsors secure passage of S. 1224.
About S-CHIP
The S-CHIP program came into effect in late 1997 under Title XXI of the
Social Security Act. Its purpose is “to provide funds
to States to enable them to initiate and expand the provision of child
health assistance to uninsured, low-income children in an effective
and efficient manner that is coordinated with other sources of health
benefits coverage for children.”
Administered federally by the Centers for Medicare & Medicaid Services,
S-CHIP is jointly funded through a federal matching program with states. Each
state designs its own program, including eligibility, benefit packages,
payment levels and procedures, within federal guidelines. More
than 6.1 million children are currently enrolled in S-CHIP programs across
the country. Most reauthorization bills call for expanding eligibility
criteria for the program.
S. 1224 was introduced on April 25th by Senators Rockefeller, Ted Kennedy
(D-MA) and Olympia Snowe (R-ME). The bill seeks to reauthorize
and modernize the State Children’s Health Insurance Plan or S-CHIP,
which will expire this September unless Congress reauthorizes it. Cosponsors
for S. 1224 are: Senators Robert Casey, Robert Jr. (D-PA); Jeff Bingaman,
(D-NM); Barack Obama (D-IL); Sherrod Brown (D-OH); Jack Reed (D-RI);
Christopher Dodd (D-CT); Daniel Inouye (D-HI); and Sheldon Whitehouse
(D-RI).
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Study Shows QIO Work in
Nursing Homes Is ‘Sound Investment’
Researchers from IPRO, the New York QIO, and the University of Albany
found in a recent study that the cost of QIO program activities in nursing
homes during the 7th Scope of Work were “a very sound investment” for
Medicare, costing far less than what is typically spent on other health
care interventions.
Using a cost-effectiveness measure called a “quality-adjusted
life year (QALY),” the study authors estimated a cost of between
$2,063 and $7,667 for each QALY gained from nursing home quality improvement
efforts attributed to the QIO program. In the U.S., a health care
treatment that produces a QALY at a cost of between $10,000 and $50,000
is commonly considered a good value.
The researchers estimated that up to 46,966 fewer long-term nursing
home residents experienced moderate or severe pain, as many as 20,288
fewer short-term residents experienced pain at these levels, and 26,832
fewer residents were put in physical restraints, due to quality improvements
achieved during the study period.
“Even with conservative assumptions about QIO program impact,
investment in QIO nursing home QI activities appears to be a good value
for health care dollars,” said study author Anthony Shih, MD, MPH,
Senior Program Officer for Quality Improvement & Efficiency with
The Commonwealth Fund. Shih worked on the study while serving as
Vice President, Quality Improvement with IPRO.
Shih and colleagues Diane M. Dewar, PhD, of the University of Albany,
and Thomas Hartman, also of IPRO, used data from three of the five quality
measures most frequently addressed by QIOs during the 7th Scope of Work
(2002-2005): short-stay residents with moderate to severe pain, long-stay
residents with moderate to severe pain, and residents with physical restraints.
Nursing homes were chosen for study because the QIO program was the
only coordinated national quality improvement effort for these providers
during this time period. “The question of the value of work
in this setting is particularly important because this was a new project
for the QIO program,” said IPRO’s Hartman. “And a priority
for CMS.”
The analysis was stratified into three levels, each assuming a percent
of overall improvement that could be attributed to QIO interventions:
50 percent, 75 percent, and 100 percent. Estimates of CMS’ investment
in the QIO program were calculated based on the total reported cost of
QIO efforts in nursing homes per QALY at each assumed attribution level.
A QALY is commonly used to evaluate the cost-effectiveness of treatment
or other interventions to improve health. If a treatment or other
action gives a person an extra year of healthy life expectancy, that
counts as one QALY. If a treatment gives a person an extra year
of life expectancy in less than perfect health, because they were partly
disabled or remained in some distress, that “quality-adjusted” year
of life has a value of less than one.
Studies have estimated that the cost of each QALY produced by mammography
screening for breast cancer and colonoscopy screening for colon cancer
is between $10,000 and $25,000; a QALY gained for a person with heart
disease treated with cholesterol medications costs between $10,000 and
$50,000; and the cost of a QALY for a patient with end-stage renal disease
receiving dialysis is between $50,000 and $100,000.
Full text of the study “Medicare’s Quality Improvement Organization
Program Value in Nursing Homes,” is available in the Spring 2007
edition of Health Care Financing Review at: http://www.cms.hhs.gov/HealthCareFinancingReview/08_2007%20Edition.asp
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Call for Papers: AHRQ-Sponsored
Health Services Research Theme Issue
The Agency for Healthcare Research and Quality is sponsoring the first
theme issue for Health Services Research on “Improving
Efficiency and Value in Health Care.” For this issue, HSR is seeking
abstracts on research results, advances that improve the reliability
and utility of research on efficiency and value, and rigorous methods
to evaluate the results to improve efficiency and value.
Possible areas of focus for original research articles include: increasing
efficiency at the provider or system level and improving the functioning
of health care markets. HSR is also looking for research methods
papers reporting methodological advances that improve the reliability
and utility of research on efficiency and value and policy analyses or
evaluations of pilot programs, demonstrations, or other large-scale initiatives.
Manuscripts must be submitted by August 21, 2007. The anticipated
publication date for the theme issue is October 2008. Author instructions
are available at: http://www.hret.org/hret/publications/call07.html.
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CAHPS LTC Survey Available
AHRQ recently released a new CAHPS survey instrument to assess the experiences
of long term care residents.
The Long-Stay Resident Instrument is the first of three CAHPS Nursing
Home Surveys being developed. The other two are a discharged resident
survey and family focused survey. Both of the resident focused
survey instruments ask questions about the nursing home’s environment,
care, communication and respect, autonomy, and activities. The
family focused survey instrument asks respondents about their perceptions
of the quality of care provided to a family member living in a nursing
home. This survey is still in the development process.
The Long-Stay Resident survey and preliminary guidelines for administration
are available at: https://www.cahps.ahrq.gov/content/products/NH/PROD_NH_Resident.asp?p=1022&s=223 The
Discharged Resident survey is still being beta tested.
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Special Open Door Forum on Registry-based Reporting for PQRI
The Centers for Medicare & Medicaid Services held a special open
door forum this month to discuss the use of registry-based reporting
data on quality measures to the Physician Quality Reporting Initiative
(PQRI). CMS is working to incorporate registry-based reporting
into PQRI in 2008.
The Tax Relief and Health Care Act of 2006 (H.R. 6111), which established
the PQRI requires the Secretary of Health and Human Services to “address
a mechanism whereby an eligible professional may provide data on quality
measures through an appropriate medical registry (such as the Society
of Thoracic Surgeons National Database).”
An audio version of the event will be available beginning the close
of business May 18 and will be accessible for three business days. PowerPoint
presentations, agendas, and other materials from the event are available
at:
http://www.cms.hhs.gov/PQRI/02_CMSSponsoredCalls.asp#TopOfPage
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