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Winter 2009


Health Care Quality and Measuring Performance

Karin Bierstein, JD, MPH
Vice President for Strategic Planning and Practice Affairs, ABC

There have been important changes to the two measures applicable to anesthesiology:

  1. Measure #30: Timing of Prophylactic Antibiotic—Administering Physician
    • This measure should now be reported when the anesthesiologist performs one of approximately 218 distinct services as defined by CPT™ codes (00100, 00102, etc.). Previously it was reported in all cases for which there was an order for antibiotic prophylaxis.
    • The complete list of eligible codes is available at http://www.asahq.org/Washington/2009pqri.htm
    • This change makes it possible for the Centers for Medicare and Medicaid Services (CMS) to decide whether the anesthesiologist qualifies for the PQRI bonus by reporting the measure in at least 80% of his or her eligible cases. When the denominator was “cases in which there was an order,” which had no CPT codes, CMS had no way to determine from claims data whether the anesthesiologist had met the 80% reporting threshold.
  2. Measure #76: Prevention of Catheter-Related Bloodstream Infections (CRBSI) – Central Venous Catheter Insertion Protocol
    • Code 93503, insertion and placement of flow-directed catheter (e.g., Swan-Ganz) for monitoring purposes, is now on the list of denominator codes. This makes Measure #76 much more important in anesthesiology practice than it was in 2007 or 2008, when it was only reported with codes 365XX, insertion of a central venous catheter.
    • The Measure #76 catheter insertion protocol now allows “acceptable alternative antiseptics per current guideline” and not just 2% chlorhexidine for cutaneous antisepsis.

The PQRI Is Just the Beginning of Measuring “Physician Quality Improvement”

In addition to the bonus payment, nonmonetary incentives are leading anesthesiology practices to participate in the PQRI. First, as noted above, virtue is its own reward. Research and reported hospital data have shown that prophylactic antibiotics are administered less than 100% of the time in many operating rooms – in some cases, considerably less than 100% of the time. Anesthesiologists have responded to these data by adopting protocols that improve the performance rate because “it’s the right thing to do.”

Many anesthesiologists also recognize that more and more systems will be scoring their performance in the future. Whether or not the metrics selected by third parties are valid indicators of the quality of medical work, they are here to stay.

Many physicians are already accustomed to receiving ratings from commercial organizations such as Health Grades, which sells reports comparing doctors on a five-star scale and also makes available at no charge the results of patient ratings (http://www.healthgrades.com). The California Office of the Patient Advocate, an independent state office within the Department of Managed Health Care, maintains a web site (http://www.opa.ca.gov/report_card/doctors.aspx) on which patients and others can check relative ratings of medical groups in two domains: (1) “meeting national standards of care” and (2) “patients rate medical groups.” Groups are evaluated on 14 specific national standards of care, including testing cholesterol for diabetic patients, not giving children with upper respiratory infections antibiotics for colds and other viruses, and screening patients for colorectal, breast and cervical cancer. See Figure 1.

A new entrant in the field of public reporting of physician quality is the Maine Health Management Coalition, whose 50 members include hospitals, medical groups, health plans and employers who work together to measure and report on quality and safety of care (http://www.mhmc.info). The MHMC, like most entities that measure physician performance, is still limited to primary care. Health Grades offers reports on numerous specialties, not including anesthesiology. There are too few nationally-recognized metrics for anesthesiologists – as well as minimal opportunities for patient-consumers to choose one group over another — for third parties to be reporting on our specialty today.

Some anesthesiology groups themselves have selected dozens of validated measures in addition to antibiotic prophylaxis (e.g., perioperative myocardial infarction, unanticipated return to OR) and have begun to measure their own performance. One large group in North Carolina, Southeast Anesthesiology Consultants, developed the Quantum Clinical Navigation System™ beginning in the mid-1990s to track and improve the quality of its clinical services and is now reporting its performance against national benchmarks to hospitals, health plans and even its malpractice insurance carrier to support higher compensation rates and lower premiums. The Quantum Clinical Navigation System™ is available through ABC. For more information, see the Fall 2008 issue of the ABC Communiqué (http://www.communiquenews.com) and/or contact ABC at 517.787.6440, Extension 4113.

As more anesthesiology quality measures work their way through the national endorsement process in which multiple stakeholders including payers and other specialties reach consensus on the adoption of new measures, it seems inevitable that quantitative scoring of comparative performance will become common. In our specialty, consumer reporting may never assume the importance that it has in primary care, but hospital and payer credentialing and maintenance of certification are going to involve evaluation of standardized performance data for anesthesiologists as well as other physicians.

Many anesthesiologists have begun participating in the PQRI to prepare themselves for a day when health plans will base differing payment amounts on individual performance data. For hospitals, that day arrived six years ago, when CMS began to reduce the annual payment update for hospitals that did not successfully report specific quality measures under one of the Medicare Hospital Quality Initiatives. Also in 2003, partnering with the Premier 300-hospital system in another Quality Initiative, CMS launched a demonstration project giving higher annual Medicare payment updates to the top-performing hospitals and, later, reducing the annual update for the lowest-scoring performers.

On October 1, 2008, CMS implemented regulations that limit payments to hospitals for treating patients for events that should “never” have occurred – the Hospital Acquired Conditions (HAC) regulations. Medicare will no longer pay a higher amount for certain cases having a secondary diagnosis for a condition that (1) was not present on admission and (2) could reasonably have been prevented by following evidence-based guidelines. If, for example a patient is admitted for pneumonia and is discharged with a new secondary diagnosis of a traumatic hip fracture, Medicare will not pay the hospital for treating the knee injury.

Medicare will still pay the surgeon and the anesthesiologist who perform the open reduction of the fracture. It is not hard to imagine that once there is an acceptable methodology for allocating a pro rata share of responsibility for a perioperative injury – think of wrong-site surgery – to the doctors as well as to the hospital, the payers will deny some or all of the claims for the physicians’ services.

It is in this light that anesthesiologists with long-range vision are preparing and practicing for a pay-for-performance future through the PQRI today.