Quality: Doctors Need to Drive This Bus!
In 1986, the Health Care Financing Administration (HCFA), which was the U.S. federal Medicare agency and is now known as the Centers for Medicare and Medicaid Services, launched a bold effort to improve medical care by releasing individual hospital mortality figures. Based on claims data, without risk adjustment, the effort was severely flawed, but gave rise to many more comprehensive efforts to assess quality. Notably, the State of New York assembled cardiac surgeons, cardiologists and statisticians with the charge of formulating a registry which was clinically meaningfully and professionally acceptable. Since inception, the New York State cardiac surgical registry has resulted in the closing of marginal programs, the retirement of marginal surgeons and a considerable decrease in cardiac surgical mortality despite an increasing patient risk profile.1 In short, markedly improved quality of cardiac surgical care.
In response to the observation that approximately one fifth of Medicare hospital patients were readmitted within a month, the Affordable Care Act in 2012 launched the Hospital Readmissions Reduction Program which began penalizing hospitals for “excess” readmissions in defined diagnosis groups. The presumption was that patients required readmission because of inadequate care or discharge planning—a presumption that has proven false for certain diagnoses. Burdened by an administrative approach, with poorly discriminating risk models that do not adequately account for key elements driving readmission, the program has resulted in a disproportionate penalty for those hospitals caring for the under-served, at risk populations—diverting funds away from those centers most in need of them to provide safety-net care.
As part of the same legislative initiative, CMS initiated the Hospital-Acquired Condition (HAC) Reduction Program in an effort to reduce the incidence of potentially preventable adverse events that occur during hospitalization—foreign objects retained after surgery, catheter related infections, surgical site infections, etc. Certainly a laudable goal. However, administration of the program has recently been show to disproportionately penalize those hospitals which have the highest standards of accreditation, as well as those with highest measures of process and outcome quality. Moreover, once again, safety net hospitals most in need of resources whave been disproportionately penalized.2 Once again, the absence of active professional involvement in administrative decisions regarding medical care has resulted in flawed methodology, inadequate clinically relevant risk adjustment and validation, and adverse outcome.
The message is clear. In the era of value-based purchasing, professional involvement and leadership in quality initiatives is critical to guide governmental initiatives and improve care for our patients.
- Hannan EL, Cozzens K, King SB 3rd, Walford G, Shah NR. The New York State cardiac registries: history, contributions, limitations, and lessons for future efforts to assess and publicly report healthcare outcomes. J Am Coll Cardiol. 2012 Jun 19;59(25):2309-16.
- Rajaram R, Chung JW, Kinnier CV, Barnard C, Mohanty, S, Pavey ES, McHugh MC, Bilimoria KY. Hospital characteristics associated with penalties in the Centers for Medicare & Medicaid Services Hosptial-Acquired Condition Reduction Program. JAMA 2015;314:375-383.