Doing Well By Doing Good: The Physician Business Case for Quality

1. Doing Well By Doing Good: The Physician Business Case for Quality Alice G. Gosfield, Esq. NERVES April 15, 2005 c.2005, Alice G. Gosfield

2. Alice G. Gosfield, J.D. Alice G. Gosfield and Associates, PC 2309 Delancey Place Philadelphia, PA 19103 (215) 735-2384 Agosfield@gosfield.com www.gosfield.com www.uft-a.com c.2005 Alice G. Gosfield

3. Overview • The quality/accountability context • Why the physician nexus matters • Understanding the doctor-patient essentials • Five principles and a theory: P4P compared • What it does, how far it can go • Why bother? c.2005 Alice G. Gosfield

4. “Every system is perfectly designed to achieve the results it gets.” Donald Berwick, M.D. c.2005 Alice G. Gosfield

5. “The contemporary moment in health policy is nothing short of a Dionysian rhapsody of regulation, the inhospitality tradition gone riot, the formal and final enshrinement of the doctrine that everything that is not mandatory is prohibited.” • ---James C. Robinson c.2005 Alice G. Gosfield

6. Today’s Quality Context: Welcome to Wonderland • Federal regulation of quality • PROs/QIOs; EMTALA; Conditions of participation for facilities • QISMC and QAPI in Medicare managed care • HCQIA c.2005 Alice G. Gosfield

7. Fraud and Abuse Enforcement • Quality failures as false claims • Nursing homes; Managed care: ‘Promises made but not kept’; Medical necessity: criminal charges to United Hospital, Tenet? • Exclusions for quality failures: • In excess of patients needs; of a quality which doesn’t meet standards • Civil money penalties for quality failures • Medical necessity, premature discharge, for payments to reduce services c.2005 Alice G. Gosfield

8. CMPs and More (continued) • Physician incentive plans that put physicians at substantial financial risk • Stark and Kickback violations • OIG Model Compliance Guidances all mention quality – new hospital guidance focuses on new quality COPs • OIG Work Plans increasingly deal with quality issues and medical necessity c.2005 Alice G. Gosfield

9. The Policy Context Today • State managed care reform legislation • Public reporting of quality data • The patients’ rights debates: a surrogate for quality • None of it engages or persuades physicians about quality c.2005 Alice G. Gosfield

10. Why Focus on Physicians? • Physician Centrality • Plenary legal authority • Portal to the system • Their Critical and Fundamental Role to the system and their business significant others (AMA Monograph) • Expertise (Reinertsen’s Axioms) • Explain, predict and change patient futures: the healing relationship c.2005 Alice G. Gosfield

11. Hazards to Time and Touch • Irrelevant documentation of many types: • E &M codes; false claims exposure; Medical necessity of services; Ministerial minutiae (CMNs for DME) c.2005 Alice G. Gosfield

12. More Hazards • Health plan programs • 1-800-nurse-from-hell • Redundant safeguards (capitation and prior authorization and encounter forms and post-payment audits) • Inconsistent formularies • Repetitive and redundant credentialing c.2005 Alice G. Gosfield

13. Time and Touch Hazards (cont’d) • Rampant consumerism • Olympic caliber Web surfing • Alternative therapies • Direct to consumer advertising • Burgeoning physician report cards • Shift to disease management approaches • Explosion of knowledge base • Clinical science as individual sport c.2005 Alice G. Gosfield

14. More Hazards • Administrative demands • To meet hospital needs • To serve on hospital committees • To manage the practice • Messaging and work flow interruptions • Pharma reps • Prescription management: writing, renewing, confronting effects of DTC • Defensive medicine c.2005 Alice G. Gosfield

15. The Biggest Hazard • Irrelevant payment systems • FFS – overuse • Capitation – underuse • P4P • Threshold quality bonus • Tiered normative bonus • CMS Gainsharing • The quality fallacy in actuarial rates c.2005 Alice G. Gosfield

16. The Point of P4P • Propel change to more science, more safety, more patient-centeredness made known with more transparency • By paying for results, processes and systems will be compelled to change by the application of purchasing power • Faster than incremental change would produce c.2005 Alice G. Gosfield

17. P4P Pitfalls • You move up to the raised bar – then what? • Where is the money coming from? • There is no contractual obligation to pay • These are add-ons to contracts that are inconsistent -- what about their UM? • Margins, margins, margins • Is a disease management program in play? • Adverse selection • The data is self-reported; are we getting what we want? c.2005 Alice G. Gosfield

18. “Every system is perfectly designed to achieve the results it gets.” Donald Berwick, M.D. c.2005 Alice G. Gosfield

19. What Makes Physicians Different? • Responsibility for individuals • Accountability for life and death • Legal captain of the ship • Collegiality and “groupiness” • Evidence based, scientific decision-making • Outcomes and quality improvement feedback (the dynamism of medicine) • Due process as the scientific method c.2005 Alice G. Gosfield

20. The New Values: EBM, CPGs and More • Systematic statements of evidence of the science • Quality of the evidence versus consensus • Some order is better than no order • “Crossing the Chasm” values: Evidence-based medicine combined with patient-centeredness made known in transparency – report cards c.2005 Alice G. Gosfield

21. STEEEP • Safe – avoiding injuries • Timely – reduce waits and harmful delays • Effective – based on scientific knowledge avoiding underuse and overuse • Efficient – avoiding waste of equipment, supplies, ideas and energies • Equitable – care that does not vary in quality because of gender, ethnicity, location and socio-economic status • Patient-centered – respectful and responsive to patient preferences, needs and values c.2005 Alice G. Gosfield

22. Escaping the Rabbit Hole: Five Principles • Standardize • Simplify • Make Clinically Relevant • Engage the Patients • Fix Accountability at the Locus of Control c.2005 Alice G. Gosfield

23. Gosfield’s Unified Field Theory in Practical Steps • Select a CPG: Better a national one • Translate into applicable ICD-9 and CPT codes • Note documentation standards: templates • Document full pathway (not just physicians) • Accommodate deviations • Engage the patient • Price the services • Measure compliance • Analyze and refine c.2005 Alice G. Gosfield

24. P4P compared c.2005 Alice G. Gosfield

25. Physicians and Plans • Creates the capacity to actually ‘brand’ for quality • Speaks to a real ‘value proposition’ • Calls the question on costs • Is the bedrock of clinical integration under antitrust rules : who needs a union when you can bargain over rates holding hands with your competitors? c.2005 Alice G. Gosfield

26. Clinical Integration for Collective Bargaining • Held out in every network settlement with the FTC to date • Elements: (1) protocols and CPGs; (2) internal review and profiling; (3) investment in infrastructure; (3) corrective action; (4) data sharing with payors • Fee bargain must be ancillary to the real reason you are doing this c.2005 Alice G. Gosfield

27. UFT-A for Physicians and Hospitals • Stark actually helps: the other 80-20 rule -- what can the hospital do for and with you? • Compliance training: help them help themselves - Stark reg • Provide ancillary staff to the 80% • Adopt practices in the hospital which are consistent with what they need in their practices for the 20% • Help them clinically integrate c.2005 Alice G. Gosfield

28. Boundaries to UFT-A • This is not for everyone – groups, virtual groups, the good guys, the innovators • Payment approach won’t work for all conditions • Standardizing even without payment change is worth doing • Reduced administrative burden lowers expenses: time is of the essence • Pilots, demos and small pockets of activity are better than grandiosity c.2005 Alice G. Gosfield

29. Advantages • Provides for unified clinical management of patients (simple and standard) • Speaks to physicians the way they think (clinically relevant) • Creates time • Lowers fraud and abuse risks • Creates common goals among all players c.2005 Alice G. Gosfield

30. Advantages (Continued) • Maximizes efficiency without sacrificing quality: the value proposition • Provides a new way to price and negotiate • Can eliminate intrusive medical management and documentation (getting out of the way) • Preempts malpractice claims, lowers liability risk and engages the patient • Goes well beyond payment in its implications c.2005 Alice G. Gosfield

31. Why bother? • What are the other options • Physicians are at the core • This is the business case for quality • You can do well by doing good if you make the right thing to do the easy thing to do • There is no one way – let 1,000 flowers bloom c.2005 Alice G. Gosfield

32. “The only progress we make in health care is the progress we make in medicine. In the daily chaos that is the US health care system there are but three elements that matter: patients, caregivers and medical technologies. Everything else is noise”. • -- JD Kleinke c.2005 Alice G. Gosfield

33. Resources Reinertsen and Gosfield, “Doing Well by Doing Good: Improving the Business Case for Quality” http://www.uft-a.com Gosfield, “Contracting for Provider Quality: Then, Now and P4P”, HEALTH LAW HANDBOOK, 2004 Ed. http://www.gosfield.com/PDF/AGG.HLH.2004.PDF Gosfield, “The Doctor-Patient Relationship As Tne Business Case for Quality,” J. of Health Law (Spring, 2004) http://www.uft-a.com/PDF/DrPatientRelationship.pdf c.2005 Alice G. Gosfield

34. More Resources Gosfield, “P4P: Bold Leaps or Baby Steps?”Pt. Safety & Qual. Healthcare (Oct/Dec 2004), http://www.psqh.com/octdec04/gosfield.html Gosfield, “P4P: Transitional At Best”, Managed Care (Jan. 2005), http://www.managedcaremag.com/archives/0501/0501.p4p_gosfield.html Ransom et al, “Reduced Medico-legal Risk by Compliance With Obstetric Clinical Pathways: A Case-Control Study, “Obstetrics & Gynecology (April 2003) pp. 751-755 c.2005 Alice G. Gosfield

35. More Resources Reinertsen “Health Care: Past, Present and Future,”Group Practice Journal, (May/April, 1997) at 38 Gosfield, “Legal Mandates for Physician Quality: Beyond Risk Management,”HEALTH LAW HANDBOOK, 2001 ed., WestGroup, pp. 285-231 FTC Advisory Opinion (www.ftc.gov/bc/adops/medsouth.htm) c.2005 Alice G. Gosfield