Quality Matters Archive

Quality Matters reported on emerging models and trends in health care delivery reform and interviews with leaders in the field. Please read its successor, Transforming Care.

  • October/November 2012 Issue
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Publications of Note

Study Suggests Impact of Medicare's P4P Program May Be Limited

To analyze the potential impact of Medicare's new hospital pay-for-performance (P4P) program for all acute-care hospitals, the authors of this study used 2009 data to calculate performance scores and projected payments for all eligible hospitals. They found that despite differences across hospitals in terms of performance, expected changes in payments were small, even for hospitals with the best and worst performance scores. Almost two-thirds of hospitals would experience changes of just a fraction of one percent. The results raise questions about whether the new pay-for-performance program will substantially alter the quality of hospital care. R. M. Werner and R. A. Dudley, "Medicare's New Hospital Value-Based Purchasing Program Is Likely to Have Only a Small Impact on Hospital Payments," Health Affairs, Sept. 2012 31(9):1932–40. 

Claims Data an Unreliable Indicator of CAUTIs

A study of claims data from 96 Michigan hospitals showed that the rate at which hospitals reported catheter-associated urinary tract infections (CAUTIs) was much lower than that expected from epidemiological survey data. This suggests that using discharge claims to monitor rates of hospital-acquired CAUTIs may be inadequate and efforts to curb hospital-acquired CAUTIs through nonpayment may be ineffective. J. A. Meddings, H. Reichert, M. A. M. Rogers et al., "Effect of Nonpayment for Hospital-Acquired, Catheter-Associated Urinary Tract Infection: A Statewide Analysis," Annals of Internal Medicine, Sept. 2012 157(5):305–12. 

Care Coordination in the Safety Net Improving

As part of the Community Tracking Study, the authors of this article examined trends in safety-net coordination activities from 2000 to 2010 within 12 U.S. communities and found a notable increase in such activities. Six of the 12 communities had made formal efforts to link uninsured people to medical homes and coordinate care with specialists in 2010, compared with only two communities in 2000. The authors also identified key attributes of safety-net coordinated care systems, such as reliance on a medical home for meeting patients' primary care needs, and lingering challenges to safety-net integration, such as competition among hospitals and community health centers for Medicaid patients. P. Cunningham, L. Felland, and L. Stark, "Safety-Net Providers in Some U.S. Communities Have Increasingly Embraced Coordinated Care Models," Health Affairs, Aug. 2012 31(8): 1698–07. 

For Some Conditions, Care Quality in Safety Nets on Par with and Non–Safety Net Hospitals

A comparison of risk-standardized mortality and readmission rates among fee-for-service Medicare beneficiaries at safety-net and non–safety net hospitals found some variation, with non–safety net hospitals outperforming safety-net hospitals on average by less than one percentage point across most conditions. Overall, rates were broadly similar. The study examined mortality and readmission rates among patients with acute myocardial infarction, heart failure, or pneumonia and found some variation in the first two conditions, and no differences for the third. The findings suggest that safety-net hospitals are performing better than many would have expected. J. S. Ross, S. M. Bernheim, E. E. Drye et al., "Based on Key Measures, Care Quality for Medicare Enrollees at Safety-Net and Non-Safety-Net Hospitals Was Almost Equal," Health Affairs, Aug. 2012 31(8):1739–48.

Success Shown Through Resident-Led Quality Improvement Initiative

A multipronged approach designed to secure resident involvement in quality improvement initiatives resulted in improvements in areas of concern to residents such as emergency department boarding and crowding, patient flow through the institution, adequacy of nursing and technical support staffing, as well as laboratory specimen handling. The three-year effort included the use of resident-generated patient safety surveys, retreats with faculty and hospital leaders to discuss survey findings, and workgroups to engage residents in institutional patient safety improvement. The authors noted the residents' perceived improvement in patient safety was also associated with observable improvements in areas of high concern for hospital leaders. J. Stueven, D. P. Sklar, P. Kaloostian et al., "A Resident-Led Institutional Patient Safety and Quality Improvement Process," American Journal of Medical Quality, Sept./Oct. 2012 27(5): 369–76. 

Resources for Hospitals to Reduce Readmissions

A commentary by Carolyn M. Clancy, M.D., director of the Agency for Healthcare Research and Quality (AHRQ), outlined the resources available to hospitals seeking to reduce preventable hospital readmissions that occur within 30 days of discharge. These include assistance from quality improvement organizations and programs such as Project RED and Project Boost, which are designed to improve discharge planning and follow-up. Under the Medicare program, hospitals that have higher-than-expected readmission rates for patients with acute myocardial infarction, heart failure, and pneumonia could see their annual Medicare payments reduced by up to 1 percent. C. M. Clancy, "Commentary: Reducing Hospital Readmissions, Aligning Financial and Quality Incentives," American Journal of Medical Quality, September/October 2012 27(5):441–3. 

Framework for Teaching Residents About High-Value, Cost-Conscious Care

This article describes a new curriculum developed by the Alliance for Academic Internal Medicine and the American College of Physicians to provide post-graduate trainees with training in the stewardship of health care resources, as well as feedback on their resource utilization and its effect on the costs of care. The curriculum includes a framework for teaching trainees to incorporate high-value, cost-conscious care principles into clinical practice. It consists of 10 case-based interactive sessions, each one hour long. C. D. Smith, "Teaching High-Value, Cost-Conscious Care to Residents: The Alliance for Academic Internal Medicine—American College of Physicians Curriculum," Annals of Internal Medicine, Aug. 2012 157(4):284–6. 

Possible Pitfalls in Medicare's Bundled Payment Program Outlined

To inform the implementation of Medicare's new bundled payment initiative, the author of this commentary shares his insights on the implementation of Medicare's prospective payment system in the 1980s. Based on his experience as the first chair of the commission on prospective payments, he cautions that the introduction of bundled payment programs requires financial support for the structural changes needed to design new care models. He also notes payment reforms must be coupled with similar reforms by private payers to ensure providers receive consistent signals to alter their behavior. Medicare's bundled payment program, begun in 2011, links payments for the acute and outpatient services that patients receive during an episode of care, with the goal of providing incentives to deliver care more efficiently while also improving quality. S. H. Altman, "The Lessons of Medicare's Prospective Payment System Show That the Bundled Payment Program Faces Challenges," Health Affairs, Sept. 2012 1(9):1923–30. 

Positive Results in Early Evaluation of WellPoint's Medical Home Pilots

A preliminary evaluation of three of WellPoint's 10 medical home pilots found that they are meeting some cost, utilization, and quality objectives. The first two—Colorado and New Hampshire—rely on incentive payments for care coordination and quality improvement on top of traditional fee-for-service payments. In Colorado, the plan achieved an 18 percent decrease in acute hospital admissions per thousand members compared with an 18 percent increase in the control group. The program also resulted in a 15 percent decrease in emergency department visits per thousand, compared with a 4 percent increase in the control group. In New Hampshire, per patient per month cost declined, but quality results were unchanged. The third pilot, in New York, pays doctors an enhanced fee that is tied to reaching quality targets. Early results from that program show that enrollees in the medical home practices had better compliance with preventive health guidelines, lower utilization rates, and lower costs compared with those in the control practices. R. S. Raskas, L. M. Latts, J. R. Hummel et al., "Early Results Show WellPoint's Patient-Centered Medical Home Pilots Have Met Some Goals for Costs, Utilization, and Quality," Health Affairs, Sept. 2012 31(9):2002–9. 

Medical Home Pilot Reveals Benefits and Challenges of Implementation

The Colorado Multipayer Patient-Centered Medical Home Pilot, which ran from May 2009 through April 2012 and engaged six health plans, the state's high-risk pool carrier, and 16 family or internal medicine practices with approximately 100,000 patients, significantly reduced emergency department visits and also reduced hospital admissions, particularly for patients with multiple chronic conditions, according to a preliminary analysis. One payer reported a return on its investment of 250 to 400 percent in the pilot. However, participants also ran into numerous obstacles, including being left to provide extra services to a large fraction of patients whose employer-sponsored insurance plans declined to pay the enhanced fees necessary to cover the cost of the patient-centered medical home expansion. M. G. Harbrecht and L. M. Latts, "Colorado's Patient-Centered Medical Home Pilot Met Numerous Obstacles, Yet Saw Results Such as Reduced Hospital Admissions," Health Affairs, Sept. 2012 31(9):2010–17. 

Medical Home Practices Need Infrastructure Support to Succeed

A study of Horizon Healthcare Services' medical home program indicates that medical homes require intensive and targeted patient care coordination supported by committed primary care leadership, as well as new payment structures that include a monthly care coordination fee and outcome-based payments. The experience also indicates that considerable non-monetary support—such as educational programming for population care coordinators, a medical home guide that offers effective ways to transform a practice into a medical home, and useful data sharing—are needed to improve the quality of care and reduce costs. U. B. Patel, C. Rathjen, and E. Rubin, "Horizon's Patient-Centered Medical Home Program Shows Practices Need Much More Than Payment Changes to Transform," Health Affairs, Sept. 2012 31(9):2018–27. 

Benefits and Weakness of Reference Pricing and Reduced Panel Size

This article compares how two benefit designs aimed at reducing regional variation in care—one relying on reference pricing and the other on centers of excellence—affect consumer choice, price, and quality. Through reference pricing, an employer or insurer makes a defined contribution toward the cost of a particular service and the patient pays the remainder. Using the alternate method—centers of excellence—employers or insurers limit coverage or strongly encourage patients to use particular hospitals for such procedures as orthopedic joint replacement, interventional cardiology, and cardiac surgery. Reference pricing retains partial coverage for care obtained from non-preferred providers, whereas some centers-of-excellence programs deny coverage altogether at some facilities. Both require extensive communication with enrollees, and both can be applied with varying degrees of stringency. The authors note that these are most useful for services for which there is substantial variation in practice, but limited variation in quality. J. C. Robinson and K. Macpherson, "Payers Test Reference Pricing and Centers of Excellence to Steer Patients to Low-Price and High-Quality Providers," Health Affairs, Sept. 2012 31(9):2028–36. 

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