Medical Device Daily Washington Editor
WASHINGTON – The phrase “quality of care” has achieved the dubious fate of buzz-phrase status in modern healthcare, but an interim report on a demonstration of the value of pay for performance (P4P) – another phrase in danger of drowning in buzz – may show that quality improvements may actually be had without leaving the U.S. economy in shambles.
The hospital quality incentive demonstration (HCID) project, undertaken by the Centers for Medicare & Medicaid Services (CMS; Baltimore) and Premier (Charlotte, North Carolina) – a group of hospitals that also has a stake in the group purchasing industry – has rounded up the figures from the first year of the three-year effort, and come up with numbers that are encouraging.
Additionally, those promoting the P4P effort clearly are attempting to address the med-tech industry's concern that P4P is simply a “low bid wins” program.
Rick Norling, Premier's president and CEO, introduced the teleconference by saying that “[t]argeting solely cost reduction without considering quality” can create problems, but that a pursuit of quality alone without factoring in cost is also problematic.
“The nexus of cost and quality,” he said, is where the nation's healthcare system needs to go. “As taxpayers, we're all concerned about the high cost of healthcare.”
The demonstration project's parameters are fairly well known. The project's coordinators recruited 260 hospitals to participate in a study of the impact of improved care standards on outcomes for five disease states: acute myocardial infarction, coronary bypass graft, heart failure, community-acquired pneumonia and hip/knee replacement.
Norling said that these conditions were chosen because all of them are both expensive and fairly common.
Some of the care standards used in the study are not particularly labor- or cost-intensive for the hospitals. Bypass and infarction patients, for instance, were directed to take aspirin routinely upon discharge, and pneumonia patients were offered smoking cessation counseling, as were the patients with heart failure.
On the other hand, patients getting replacement joints or coronary bypasses received prophylactic antibiotics within an hour of surgery. Doctors also assessed those with heart failure for left ventricular function and prescribed angiontensin-converting enzyme inhibitors to treat any problems with left ventricular systolic function.
Applicant hospitals had to go through a quality systems gauntlet provided courtesy of the federal government's primary quality standard bearers, the Joint Commission on Accreditation of Healthcare Organizations (Oakbrook Terrace, Illinois) and the Agency for Healthcare Research and Quality (both Washington).
Data from the first year, commencing Oct. 1, 2003, show that the consistent application of high standards of quality can improve outcomes by a substantial margin, and the incentives supplied by CMS help to ensure that hospital administrators can rationalize the extra effort needed to improve care standards.
Stephanie Alexander, Premier's senior vice president for healthcare informatics, presented the argument that the healthcare industry “has not demonstrated a clear relationship between cost and quality, until now,” adding, “the number of patients studied makes the results conclusive.”
The data include information on outcomes for more than 77,000 patients.
“In one year alone, if all heart bypass patients had received all high reliable care,” 3,000 fewer Americans would lose their lives to congestive heart failure, Alexander said. The numbers for pneumonia indicate that with the improved quality of care, hospitals would see 6,000 fewer readmissions.
An extrapolation from the HCID numbers suggests that national compliance with the standards could cut the total number of patient-days in hospitals by half a million. Applying the HCID standards for pneumonia and coronary bypass could knock as much as $1 billion off the national healthcare tab.
Alexander said that the researchers believed this to be “a conservative estimate” because the hospitals enrolled in the project rank among the best in the U.S. and so already deliver higher-quality care than is typical.
Mark Wynn, PhD, CMS's director of payment policy demonstration projects, reminded the audience that “Medicare has had a continuing and increased focus on quality of care” under administrator Mark McClellan's leadership, and he described the project as “a testbed” for CMS's future quality care emphasis.
Wynn reassured industry and patients that hospital size has no demonstrable correlation with quality. “Top performers included large and small hospitals,” he noted.
He also pointed out that this project suggests that improved quality of care promises cost savings for CMS, in part, because such effort will cut down on readmissions as well as “complications, many of which are paid at higher DRG rates.”
Norling admitted that the mere focus on quality may have had some impact on the numbers.
However, he insisted that the so-called “Hawthorne effect” was not the only driver of the numbers in question – the Hawthorne effect named for a 1920s study, at Western Electric's Hawthorne plant in Chicago, demonstrating that a feeling of importance to a group cause can boost performance.
“It's true that when you shine a light on something, improvements tend to occur,” Norling said. But he added: “I think there are systemic effects” at work in the numbers, rather than such an effect.
Wynn noted that the Deficit Reduction Act of 2005, which gave life to the HCID project, requires that CMS report back to Congress. While CMS has “a committee addressing the issue of [further] incentives,” he said that “we're just getting going on the report” that will go to Congress.