I Went to Law School - How in the World Am I Supposed to Help with

Quality Initiatives?

Business Law and Governance Practice Group

Hospitals and Health Systems Practice Group

In-House Counsel Practice Group

Enterprise Risk Management Task Force

Americal Health Lawyers Association

February 10, 2012

Orlando, FL

Robin Locke Nagele, Esq.

Principal

Post & Schell, P.C.

1600 JFK Boulevard

13th Floor

Philadelphia, PA 19103

215-587-1114

A.Threshold Questions

1.WHY employ Quality Metrics?

a.Mandatory Payment Programs

i.Medicare and Medicaid HAC programs

ii.Medicare Value Based Purchasing (VBP) program

iii.Private payer-mandated quality metrics.

b.Voluntary Payment Programs

  1. Medicare Shared Savings Program
  2. Medicare Bundled Savings Demonstration Programs
  3. CMI Pioneer ACO Program
  4. DRA Medicare Hospital Gainsharing Demonstration Program
  5. Medicare’s Physician Group Practice Demonstration Program
  6. Prometheus Payment Model
  1. Public Reporting – Mandatory and Voluntary
  1. CMS’s Hospital Compare
  2. CMS’s Physician Quality Reporting System (PQRS)
  3. State websites, e.g.: Pennylvania Health Care Quality Alliance (PHQCA) and Pennsylvania Health Care Cost Containment Council (PHC4)
  4. Private entities: HealthGrades, Leapfrog Group, Checkpoint, Bridges to Excellence

d.Accreditation requirements

i.The Joint Commission (National Patient Safety Goals)

ii.National Committee on Quality Assurance (NCQA)

iii.Det Norske Veritas (DNV)

e.Provider-Driven Quality Improvement Goals

2.WHO is employing them and in what setting?

a.Community Hospital

b.Academic Medical Center (AMC)

c.Physician Practice

  1. Integrated Health System

e.Joint Venture Ambulatory Surgery Center (ASC)

  1. Accountable Care Organization (ACO)
  2. Managed Care Organization (MCO)

3.HOW will the Quality Metrics be used?

a.Establishing eligibility for bonus payments (e.g., physician employment contracts, Medicare Shared Savings program)

b.Avoiding payment reduction (e.g. HAC, VBP and other payor programs)

c.Acquiring or maintaining clinical privileges (e.g., hospital, ASC or ACO quality oversight programs)

4.WHERE do the Quality Metrics come from?

  1. External industry benchmarks (TJC, NQF, AHRQ, etc.)
  2. Specific payor requirements (VPB, HACs, etc.)
  3. Internally derived quality standards
  4. Provider-specific evidence-based protocols

5.WHAT is the ultimate goal?

a.Improve quality and efficiency of services

b.Enhance patient satisfaction

c.Access payment incentives

d.Maintain or improve competitive position

B.Quality Domains[1]

1.Process

a.Evidence-based practices that have been demonstrated to be linked to improved outcomes – e.g., aspirin on admission and beta blockers on discharge for cardiac patients.

2.Access

a.Evidence-based measures of timely and appropriate healthcare linked to improved outcomes – e.g., annual checkup for pediatric patients.

3.Outcome

a.Health status of a patient resulting from health care – e.g., morbidity and mortality data.

4.Structure

a.An organizational feature linked to high quality health care – e.g., use of a CPOE system, which has been shown to reduce medication errors.

5.Patient Experience

a.A patient’s reported observations as to whether their healthcare encounter met their expectations, values and preferences – e.g., high scores on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey (used by CMS in the VBP program).

C.Usefulness of Chosen Metrics

1.Importance

a.Will the achievement of the chosen metric measurably improve patient quality or safety?

2.Scientific Soundness

a.Has the metric been adequately tested and proven in the relevant healthcare setting?

3.Feasibility of Measurement

a.Does the provider have in place an adequate system to accurately and efficiently measure the practitioner’s level of adherence to the metric, e.g. through:

  1. Electronic Health Record (EHR)
  2. Quality or claims database
  3. Results of survey data

D.Design Process

  1. Engage key stakeholders

a.Physicians and healthcare team members, operations, information technology, and finance.

  1. Identify relevant domains and external mandates

a. Mandatory: NPSG, HAC, VBP metrics;

b. Voluntary (AHRQ, NQF and specialty society metrics).

  1. Adapt and refine for specific healthcare setting.

a. Determine an appropriate range and number

b. Define the treatment goals in concrete, setting specific terms.

c.Determine method and feasibility of measuring (e.g. through EHR)

d.Design numeric expectations to match oversight goals (accountability, financial rewards)

e.Determine measures of improvement[2]

i.absolute performance

ii.relative performance

iii.improved performance

f.Determine time frame and whether the goals remain static or increase over time (e.g., Year 1 – 90% compliance, Year 2 – 95% compliance, Year 3 98% compliance)

g.Achieve consensus among stakeholder group.

  1. Identify rewards/sanctions for success/failure in meeting goals.

a.Financial Rewards

i.bonus payment for meeting targets – flat fee, percentage, unit-based.

ii.return of withhold

iii.upward adjustment on future payments (“quality increase”)

iv.group vs. individual rewards

b.Financial Penalties

i.reduced payment for failure to meet targets.

ii.loss of withhold

iii.downward adjustment on future payments (“quality decrease”)

iv.group vs. individual penalties.

c.Employment consequences

i.warning, probation, termination.

d.“Privileging” consequences

i.peer review, discipline, corrective action

e.What about impact on JV owners?

  1. Legal Exposures

a.Compliance with regulatory requirements

b.Medical Staff privileging exposures

c.Breach of contract and business torts

d.Antitrust liability

E.Resources:

  1. Agency for Healthcare Quality and Research (AHRQ):
  2. Center for Medicare and Medicaid Innovation (CMI):
  3. CMS Hospital Compare website:
  4. CMS Site for Value-Based Purchasing:
  5. Dartmouth Atlas of Healthcare:
  6. Det Norske Veritas (DNV):
  7. Healthcare Incentives Improvement Institute, Inc.:
  8. Healthgrades:
  9. Leapfrog Group:
  10. National Quality Forum (NQF):
  11. National Committee for Quality Assurance:
  12. National Quality Measures Clearinghouse (NQMC):
  13. The Joint Commission:

1

[1] See,

[2]See, Cromwell, J. Trisolini, M.G., Pope, G.C., Mitchell, J.B., and Greenwald, L.M., Eds., Pay for Performance in Healthcare: Methods and Approaches, RTI Press Publication No. BK-0002-1103 (2011),