Data from landmark P4P project are in: Learn what top-rated organizations did
High performers are getting financial bonuses
How would you like an extra $500,000 to spend on quality projects at your organization? It’s no secret which hospitals are on the receiving end of significant reimbursement, now that the long-awaited quality data from the Centers for Medicare & Medicaid (CMS)/Premier Hospital Quality Incentive Demonstration Project have been released.
For the 270 participating hospitals, performance was tracked for 34 quality indicators for acute myocardial infarction (AMI), coronary artery bypass graft (CABG), heart failure, pneumonia, and hip and knee replacement surgery, with annual incentives paid to top performers.
The median performance composite score went up 7.5% in the project’s first year. (For a complete review of the demonstration, the year-one results, and to view hospitals ranking in the top 50% for each focus area, visit www.premierinc.com/qualitydemo.) Medicare will reward high performers with bonuses totaling $7 million per year for a total of $21 million, while poorly performing hospitals may face financial penalties.
However, the extra reimbursement wasn’t the biggest motivating factor, according to quality leaders. "This was not about the money for us. It cost us money to participate," says Alison Page, MHA, director of patient safety at Fairview Hospital, part of a large integrated system in Minnesota.
"We did this to create organizational focus and to build energy around moving clinical indicators, and also to be more transparent with our data," says Page. "We decided to sign up because we saw the need to demonstrate quality in a way the public can understand. It’s coming down the pike, and we are going to have to do that."
Fairview Lakes Regional Medical Center placed in the top deciles for all three clinical conditions in which they participated. If the organization had performed in the top 1% for everything, it would have meant about half a million dollars, Page notes. "What did come back was about a quarter million. The money is going back to the hospitals where the good work was done."
Additional reimbursement gives a "tangible reward for our focus on quality," says Barbara Muntz, vice president of performance improvement at Texas Health Resources, a 13-hospital system receiving $356,628 this year. "We are committed to providing exceptional care with or without additional incentives," she says. "Regardless of additional reimbursement, I am convinced that our patients are receiving better care and services because of our participation in the demonstration project."
The hospital boards and executive and medical staff leaders committed to quality and patient safety programs by making them part of the strategic plan and allocating the human and financial resources necessary for success, says Muntz.
"Our CEO made it very clear that quality of care is the job of administration and operational leaders," Page says. "Clinical quality outcomes will be a large portion of our incentive plan for executives. It was a priority in the past, but we didn’t tie incentives to outcomes."
The prospect of high quality being public knowledge is another strong incentive.
"We are rapidly expanding our programs and getting into tertiary care programs, and we have pretty stiff competition with New York City hospitals," says Charles A. Riccobono, MD, director of performance improvement and chief quality officer at Hackensack (NJ) University Medical Center. "So obviously we want to be known for quality. We want our patient population to be confident choosing us."
Of the $8.85 million CMS is awarding for year one, the largest single award, $326,000, will go to Hackensack (NJ) University Medical Center for care of patients with CABG surgical procedures. Hackensack was a top performer in all five areas and cared for more Medicare patients than any other provider, notes Riccobono, adding that its total award will be nearly $848,000.
As a participant in the Institute for Healthcare Improvement’s "Pursuing Perfection" initiative, the organization already had assembled teams to address core measures including AMI, congestive heart failure, and pneumonia.
"So when this came along, we decided to participate. Also, we are changing our data vendor to Premier, which was an additional impetus," Riccobono says.
Teams were formed with physicians, nursing staff, and ancillary personnel, with care processes examined using data-driven principles. "We tweaked processes and tested small changes by having teams collect data with rapid cycle improvement," he says.
Each organization reports using data to identify problem areas and addressing these early on. "Exceptional patient care depends heavily on effective communication between caregivers. As we worked on care processes related to these clinical conditions, we identified opportunities to improve communications and handoffs between physicians, nurses, pharmacists, and discharge planners," Muntz says.
To address this, standardized orders were developed to improve cycle times, with parallel processes used instead of sequential. For instance, to speed delays in getting patients to the cardiac catheterization lab, the entire team is called simultaneously, instead of calling the cardiologist, waiting for a call back, then calling in the team.
"The sharing of great ideas and best practices between our hospitals has given great power to the program," Muntz adds. All data used for the CMS initiative were obtained through chart abstraction, she notes. "Accurate abstraction requires clinically oriented staff that are well-trained and equipped with the right tools."
Web-based data collection tools were used for core measures long before the CMS project began, so improvement efforts were well under way at the project’s kick-off, reports Muntz. "We have learned that concurrent review allows immediate feedback to caregivers and helps them to improve the documentation of their care," she says. "Accurate documentation of care delivered is a key success factor for this project."
At Hackensack University Medical Center, one early obstacle involved the changing relationship between nurses and physicians, says Riccobono. "We were asking nurses to do things that they hadn’t before, which made them somewhat uncomfortable," he says.
For example, if nurses saw in the patient’s chart that aspirin hadn’t been given, a call would have to be made to the doctor to remind him or her. "Doctors and nurses were not used to that, but we got past it," says Riccobono. "We used advanced practice nurses who had a certain degree of expertise and professional respect, which made it easier to smooth over initially."
Another problem involved getting AMI patients to the cath lab more quickly. The original process involved the patient choosing a cardiologist who eventually came to the ED. "We did a lot of work with the ED and primary care physicians and the cardiologists to streamline the process," says Riccobono.
The new process involves primary care physicians identifying cardiologists placed on a call schedule, with a call going out simultaneously to cardiologists and primary care physicians. "That was a big breakthrough," says Riccobono. "We also call the cath lab team at the same time, so they are on their way in already. What used to take a long time in sequential fashion now takes much less time."
Other key changes: The electrocardiogram is now done in the ambulance and transmitted to the ED before the patient’s arrival, results of cardiac enzymes come back more quickly, and there is faster access to electrocardiogram and chest X-ray. "We are trying to make care processes as smooth as possible. Our numbers show a dramatic reduction in the amount of time," says Riccobono.
At Fairview Health, there was work to do to improve the actual care being delivered, such as giving aspirin on arrival — but equally important was documenting, tracking, and extracting that information, says Page.
"Of the 34 indicators we had to track for CMS, we learned right off the bat that about two-thirds of them were not readily available," Page says. "You really had to dig to find that information — we had to do a lot of manual work. And in many cases, it wasn’t documented at all."
There was resistance from clinical staff to improving documentation, says Page. "A lot of people said, We are delivering the right care, we just can’t get the data!’ And what we said was Tough luck! Your ability to extract the information from paper records is equally important to your ability to actually improve the process. It’s no longer an excuse that you can’t get the data.’"
Coders now use a template to extract data, and charts with missing documentation are pulled and sent to a clinical reviewer.
Once data were being extracted consistently, problem areas with care delivery were revealed. "It brought to light what we were actually doing and not doing — how frequently are we getting beta-blockers or antibiotics timed correctly?" says Page. "That has been very enlightening. That information is being looped right back to the doctors for those patients they cared for."
Although the CMS indicators are evidence-based, there was resistance among some of the medical staff to making these changes, Page notes. "Some of the doctors do not believe that the CMS things are the right thing to do. So those have been difficult conversations," she says.
"People were hesitant about participating at first. But this has been very good for us — it has gotten all eyes focused on care," says Page.
The project has created opportunities to share improvements, which often is difficult in a large system, adds Page. Staff attended an all-day meeting called "A Day of Sharing" to exchange solutions for problem areas such as pneumonia management and smoking cessation. "People had trouble getting those numbers up," she says.
Each hospital shares its best practices and also the enforcement procedures used to make sure nothing falls through the cracks, says Page.
"Then we talk about the best ideas. And at the end of the day, we come to a decision about what to do the same and what to do differently. Lots of times, we have the experts right in our own system and we don’t even know it," she says. "We found out in our company that there are three or four ways of assessing patients for falls. But there is one best way to do it, which is supported in the literature — so why not do it that way?"
Although many organizations achieve short-term benefits after putting processes in place, not everyone can sustain the gains, notes Page. "We track the data, make it very open, and link outcomes to incentive compensation. This keeps people focused on it."
At Hackensack, gains are sustained by ongoing analysis of all variances, says Riccobono. "Additionally, we use failure mode and effects analysis to detect potential weaknesses in a process, leading at times to appropriate reengineering."
When the CMS pilot project came along, it allowed quality leaders to leapfrog over a lot of organizational red tape, adds Page. "People in our organization are very consensus-driven, and we would have talked about it for five years. By signing on, we avoided that and could jump start our organizational efforts around quality."
Future of P4P?
Pay-for-performance isn’t just a passing fad but a major sea change in health care and quality, according to quality leaders interviewed by Hospital Peer Review.
"In the 1970s, reimbursement was based on cost. Then in 1983, you were given a flat amount based on diagnosis. Payers are now saying that reimbursement will be based on quality of outcomes," Page says. The CMS project is a harbinger of what’s to come with private insurers, she adds. "When the federal government switched to paying based on diagnosis, everyone followed suit," says Page.
"There is clearly a national interest in pay-for-performance, with congressional committees working on this," says Riccobono.
One argument is that bonuses should be based on the amount of improvement shown, notes Riccobono. "It is nice that we received the money, but the issue is, how do you best drive the overall quality agenda?" he says. "Some people think even if you are lower down and showed greater improvement, you should be rewarded for that."
One of the problems is that quality incentives aren’t always aligned, says Riccobono. "It costs money to be efficient and provide quality," he says. "It will pay off in the long run, but in the short run you can actually lose money in a particular hospital. So the bonus incentive isn’t great unless it is palpably felt inside an organization. Some feel that the government should directly share the cost savings with hospitals."
It’s most important that the right measures are picked and that these are closely scrutinized, says Riccobono.
"That is evolving too," he says. "Already, there is some literature that says paying too much attention to multiple measures can take your eye off the total patient, particularly with the elderly who have multiple disease processes."
The project’s success has long-term implications for pay-for-performance, Muntz concludes. "I don’t think it will be long before CMS looks at pay-for-performance for physicians," she says. "Both CMS and private payers seem to be moving in this direction."
Pay for performance is the "next big wave," says Page.
"Quality of care needs to be very readily available to the general public in a way they can understand it," she says. "We want to get in front of that train. This is just the tip of the iceberg."
How would you like an extra $500,000 to spend on quality projects at your organization? Its no secret which hospitals are on the receiving end of significant reimbursement, now that the long-awaited quality data from the Centers for Medicare & Medicaid (CMS)/Premier Hospital Quality Incentive Demonstration Project have been released.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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