While anesthesiologists may use bench-marking for both quality improvement and marketing, the biggest incentive, according to Robert S. Lagasse, MD, is Medicare reimbursement, which has become increasingly tied to quality metrics.
“Benchmarking will determine reimbursement rates,” said Dr. Lagasse, professor and vice chair for Quality Management and Regulatory Affairs at Yale School of Medicine, in New Haven, Conn., “and is likely to evolve toward ‘triple aim,’ with more emphasis on effectiveness, patient satisfaction, and cost and return on investment.”
Dr. Lagasse, who is also on the advisory board of Anesthesiology News, added, “Benchmarking clinical performance is likely to be part of your current practice. You just need to see which of those initiatives your hospital is participating in and how they can break down the data for your anesthesia group’s individual providers.”
As Dr. Lagasse explained at the 2016 American Society of Anesthesiologists Practice Management annual meeting, hospitals and physicians are subject to regulations from the Centers for Medicare & Medicaid Services (CMS), called the “Medicare Conditions of Participation” (CoPs). Under the Social Security Act, CMS may recognize national accrediting organizations as having so-called deeming authority if they demonstrate that their health and safety standards and their survey processes meet or exceed those used by CMS for the CoPs.
“If you are accredited by one of these agencies with deeming authority,” said Dr. Lagasse, “it doesn’t mean you won’t get surveyed by CMS, but it makes it a lot less likely.”
The Joint Commission: This organization determines compliance with their standards by assessing specific elements of performance. The standard that says the hospital must collect data to monitor its performance specify exactly which data should be collected. Those that apply directly to anesthesiologists include operative or other procedures that place patients at risk for disability or death; significant medication errors; significant adverse drug reactions; patient perception of the safety and quality of care, treatment and services; adverse events related to using moderate or deep sedation or anesthesia; use of blood and blood components; all confirmed transfusion reactions; and the results of resuscitation.
Professional Practice Evaluation (PPE): According to Dr. Lagasse, there are two different types: ongoing and focused (i.e., a time-limited evaluation). Ongoing PPE includes:
- A clearly defined process that facilitates the evaluation of each practitioner’s practice
- Individual departments determining the type of data to be collected and the organized medical staff approving the measures
- Use of ongoing PPE information to determine whether to continue, limit or revoke existing privilege(s), or initiate a period of focused PPE.
ORYX: This Joint Commission initiative integrates outcomes and other performance measurement data into the accreditation process. Anesthesiology-specific measure sets include tobacco use treatment, the hospital outpatient department and the Surgical Care Improvement Project (SCIP).
SCIP measures that are effective in 2016 include prophylactic antibiotic received within an hour of incision, glucose control in cardiac surgery, urinary catheter removed on postoperative day 1 and perioperative temperature management.
Det Norske Veritas: “DNV, another accrediting agency, markets themselves as being less prescriptive,” said Dr. Lagasse. Anesthesia-specific minimum requirements include medication use, operative and invasive procedures, anesthesia and moderate sedation, blood and blood components, effectiveness of pain management systems, patient flow, customer satisfaction (for clinical staff and support staff), discrepancy pathology reports, unanticipated deaths, adverse events, near misses, and clinical or pertinent processes for both clinical and nonclinical personnel.
CMS Regulatory Agencies
The Physician Quality Reporting System (PQRS) is a program for individual eligible professionals and group practices to report to Medicare on their quality of care. In 2015, the program began applying negative payment adjustments for failure to satisfactorily report data. Quality measures include health outcomes, patient perceptions and organizational structure.
“By reporting quality measures,” said Dr. Lagasse, “clinicians can assess the quality of their care, quantify how often they meet metric benchmarks and view their metrics on Physician Compare.”
According to Dr. Lagasse, the latter expanded in 2015 to include PQRS individual measures as well as added patient satisfaction surveys (i.e., Consumer Assessment of Healthcare Providers and Systems [CAHPS]). In 2016, Physician Compare expanded to include Qualified Clinical Data Registry (QCDR) measures.
The following 2016 PQRS reporting measures (and their numbers) have relevance to anesthesiology providers: prevention of catheter-related bloodstream infections (76), continued administration of β-blockers (44), pain under control within 48 hours (342), preoperative risk assessment (358), documentation of current medications (130) and tobacco use screening and intervention (226).
For claims reporting, participants must report on at least nine measures across three National Quality Strategy (NQS) domains for at least 50% of their Medicare Part B FFS (fee for service) patients.
NQS domains include person- and caregiver-centered outcomes; patient safety; communication and care coordination; community, population and public health; efficiency and cost reduction; and effective clinical care.
Introduced in 2014, the QCDR is not limited to measures within PQRS and reports on all patients, not just Medicare beneficiaries. A QCDR may submit a maximum of 30 non-PQRS measures from the following sources: CAHPS, National Quality Forum, measures used by boards or specialty societies, or measures used in regional quality collaborations.
Future of Benchmarking
Looking ahead, Dr. Lagasse predicted that evidence-based research evaluating process and outcomes will evolve to effectiveness research that will incorporate cost and return on investment. He also sees the emergence of tiered health care via taxation.
“It’s no longer a dirty word to talk about cost when you talk about interventions,” said Dr. Lagasse. “As we start to focus on the dollars, I think our patients will want to contribute finances to make decisions about what kind of care they’re going to receive.”
Sam Wald, MD, MBA, associate chief medical officer, Perioperative and Interventional Services at Stanford School of Medicine, in Stanford, Calif., said Dr. Lagasse provided a valuable overview of an increasingly important component of reimbursement.
“I think we first need to know how we’re being measured by outside organizations and the regulatory body,” said Dr. Wald. “The next step is to figure out how we’re actually going to implement systems and process in our hospital so we can meet those quality measures.”