Q&A on proposed CMS' 2010 IPPS rule
How far does it go toward VPB?
David Harlow, a health care lawyer and consultant, is the founder of The Harlow Group LLC and a "blawger" at http://healthblawg.typepad.com.
Q: It doesn't seem with the proposed inpatient prospective payment system for 2010 that there was a huge leap toward value-based purchasing (VPB).
A: No. There's slight expansions on the quality measures that are used and how those will change in the future under the RHQDAPU [Reporting Hospital Quality Data for Annual Payment Update initiative]. So there's some interesting issues there to consider. My problem with that set of measures and those incentives is that the incentive payment that's available to hospitals is incredibly small, and in terms of VBP, that's really not value-based purchasing. It's paying for reporting more than paying for performance. And virtually all of the measures are process measures rather than outcome measures.
In my mind, in order to achieve a working VBP model, there needs to be a move both to increase the number, the proportion of measures used that are outcomes measures, and also increasing the percentage of the payment that's at risk.
Q: So the quality measure changes don't require much more work?
A: There's only one or two new measures added this year. Not a big number. But they've published about 70 additional measures that they're thinking about adding over the next couple of years. And the whole thing started with 10 measures, and the idea was to see if people would actually report on measures so they wouldn't have 2% of their payments withheld.
Virtually everyone said, "Sure we'll report on 10 measures to avoid having 2% of our payment withheld." Now we're getting up to a point where there's actually a burden involved in collecting and reporting the measures, especially if we're up to 40 or 50 now and they want to add up to another 70 possibly. That's huge.
Another question there, in addition to the expense involved in collecting and reporting those, there's some talk in this rule about whether these measures can be abstracted automatically from electronic health records. Certainly that would be an improvement.
The question is really if you're looking at 70 things to assess quality of care provided at a given institution, isn't there really a core measure set of six or eight things that can really give you the same answer? That would be predictive of the outcomes of the 70 measures?
Let's say there's 70 good measures you want to follow, but I'd say it's more likely than not there's six or eight measures you could follow that would be predictive of the outcomes on the rest.
And this is something that has been pursued in the private sector. For example, by The Leapfrog Group. And I think that's an area in which the government could learn from the private sector.
Q: CMS has said it limited the number of quality measure changes this year because soon these measures can be collected and reported on through electronic health records (EHRs) eliminating the burdensome workload on hospitals.
A: We hear this number being batted around of $19 billion available in incentives for implementing an EHR. That number, if you look at the numbers that may flow to an individual or hospital, the dollars available are really dwarfed by implementation costs. So someone doing a rationale cost-benefit analysis, if they're motivated only by the incentive funds, they're not going to do it. So there has to be another reason to do it. And it has to be not a stick but some other carrot.
And that's why I think that the incentives, the bonuses that are going to be available for high-quality care should be greater than 2% because that's not really sufficient incentive to move the hospital to really spend time and resources and energy in revamping their workflow.
To many hospitals, it's not just about slapping an EHR system on top of an existing system. What I've seen as health care providers and networks are implementing EHR systems with real connectivity built into them, it ends up reinventing the workflow of those provider organizations. They're often built around inefficient paper systems and things have sort of run up organically over the years or we've done it this way because we've always done it this way and putting everything on the computer system is really an opportunity for people to rethink their workflow.
[EHRs are] expensive. If a hospital is to do it itself, that alone can run into the six figures. So it's not a simple matter to say yes this is an interoperable system so you can press a button and everything gets uploaded instantly. It doesn't really work that way.
David Harlow, a health care lawyer and consultant, is the founder of The Harlow Group LLC and a "blawger" at http://healthblawg.typepad.com.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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