Clinical Quality Measurement and Finances

1. Clinical Quality Measurement and Finances Michael F. Gervasi, DO, CHCQM CMO, Florida Community Health Centers, Inc.

2. Quality Improvement Started in the 60’s Expanded in the 80’s Demming, Baldridge, et.al.

3. Healthcare QI • Started in the early 80’s • Two driving forces: …Increased litigation …Rising cost demanded better value (Remember the word “value”)

4. Quality Assurance • Early quality initiatives • Bad outcome – determine who was at fault • Individual focused • Assign blame

6. Quality Improvement • Moved away from individuals and blame • More of a systems approach • “Every system is perfectly capable of delivering the outcomes for which it is designed” W. Edward Deming

7. Alphabet soup • CQI / TQM • CPI • Lean Six-sigma • ISO 9001

8. They all aim to: …decrease variability …increase reliability …reduce waste

9. What would 99.9% reliability mean? • 1 hour of unsafe drinking water each month. • 2 unsafe plane landings per day at O’Hare Airport in Chicago • 16,000 pieces of mail lost every hour. • 22,000 checks deducted from the wrong bank account each hour. • 20,000 incorrect prescriptions every year. • 500 incorrect operations each week Adapted from VA National Center for Patient Safety

10. Business started QI; What does business think of it now?

11. “The 1960’s and 1970s brought a dawning realization that market share is key to a company’s growth and profitability.” “The 1980’s have shown just as clearly that one factor above all others – quality – drives market share.” Buzzell & Gale The PIMS Principles (Profit Input of Market Strategy)

12. Does Quality Really Pay? “There is a proven bottom-line economic benefit accruing to an organization that becomes adept at deploying quality management principles and practices.” from “Making the Economic Case for Quality” An ASQ white paper by John Ryan

13. PIMS – Began in 1972 Described in detail in 1987 Bradley T. Gale of the Strategic Planning Institute and Robert D. Buzzell of Harvard University. Over a period of years, PIMS amassed a large data base documenting the strategies and financial results of more than 450 companies and nearly 3000 business units.

14. In the long run, the most important factor affecting a business unit’s performance is the quality of its products and services relative to those of its competitors. Buzzell & Gale The PIMS Principles

15. What About Health Care? “…In nearly all cases, companies that used total quality management practices achieved better employee relations, higher productivity, greater customer satisfaction, increased market share, and improved profitability.” GAO Study, 1991

16. From a financial standpoint, many practices still use the old QA (quality assurance) mentality.

17. Denials • Services billed do not meet medical necessity criteria established by the payer. • Supporting documentation was not provided or was insufficient to support the services billed. • Eligibility or authorization was not established. • Items were not keyed accurately. • Etc. Etc. Etc.

18. WHAT DO WE DO? QA approach – send a memo re: “our policy”, counseling, discipline. QI approach – need to educate, create system to check claims, “back end editing” Document improvement.

19. Medical “Quality” • What is it? • Are we delivering a “product”? • Does it have specs, dimensions? • Is it “outcomes”? • It can mean different things to different people (payers, patients, administrators) “I can’t define it, but I know it when I see it.”

20. HRSA has defined it for us! Quality healthcare is the provision of appropriate services to individuals and populations that are consistent with current professional knowledge, in a technically competent manner, with good communication, shared decision making, and cultural sensitivity. It is evidence based, increases the likelihood of desired health outcomes, and addresses the six areas most likely to benefit patients according to “Crossing the Quality Chasm: A new Health System for the 21st Century. National Academy Press, 2001

21. The Six Areas • Safe: Avoiding injuries to patients from the care that is intended to help them. (patient safety / risk management) 2) Effective: providing services based on scientific knowledge to all who could benefit (standard of care), and refrain from providing services to those not likely to benefit (medical necessity / fraud and abuse)

22. The Six Areas 3) Patient Centered: Providing care that is respectful of and responsive to individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions (???????????????) 4) Timely: Reducing waits and sometimes harmful delays for both those who receive and those who give care (risk management / patient safety)

23. The Six Areas 5) Efficient: Avoiding waste, including waste of equipment, supplies, ideas, and energy (Six Sigma) 6) Equitable: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status (discrimination suits)

24. The Economic Benefits of CQI are both Tangible and Intangible

25. Tangible • Incentive bonuses from payers: …usually from cost savings (pharmacy, hospital LOS, etc.) …HEDIS measures …Leapfrog Group …P4P / PQRI …Multiple measures, including patient satisfaction (BC/BS, 1990’s, Dr. Mark Bloom) …Basically – give money for certain behaviors

26. Tangible • Better documentation + better coding = increased revenue • Fewer denials (medical necessity, confirmation of coverage, eligibility, etc) = increased revenue • “Time is money” – spending time on office visits and labs denied is money lost.

27. Intangible • Patient satisfaction • Referrals • Cycle time • No shows

28. Intangible Standard of Care and Medical Quality …We run reports and do chart audits to ensure the standard of care is being met. …We report our measures to various organizations

29. UDS Requirements …Trimester of entry into prenatal care …Childhood immunization rates …Cancer screenings …HTN – BP <140/90 during measurement year …DM – A1C <7%, A1C >7 - <9%, A1C >9% …HDC reporting – chronic disease measures.

30. Do Something With the Data! • Can generate office visits on patients not at goal. • Meets medical necessity regulations • Avoid clinical inertia

31. Example • 2300 diabetics in HDC registry • 30% (690) are at goal (A1C<7%) • 1610 not at goal • HDC compliance is at least 2 A1C’s/year, 6 months apart. • If not at goal, should see them at least every 3 months (ok for medical necessity)

32. Assume just half the uncontrolled patients (805) had just 1 extra office visit (low est.) • Assume a SFS rate of 50% (probably high) • Assume $100 per visit for the rest. 400 visits x $100/visit = $40,000 For just one parameter!

33. Using this concept for the other UDS measures and the HDC measures can generate significant income! • QI department and clinical staff must work together. • Look at data collection as an investment, not simply a requirement.