Potential unintended consequences due to Medicare's "no pay for errors" rule? A randomized controlled trial of an educational intervention with internal medicine residents

Prenatal aneuploidy screening in a low-risk Hispanic population: price elasticity and cost-effectiveness

BACKGROUND

In October 2015, the Massachusetts Medicaid program temporarily stopped reimbursement for procedures in which the International Classification of Diseases, Tenth Edition, code for serum aneuploidy screening used by certain communities was stipulated. This change led to a substantial number of patients who went without aneuploidy screening for approximately 3 years.

OBJECTIVE

This study aimed to determine the change in use and cost-effectiveness of prenatal aneuploidy serum screening in a low-risk Hispanic Medicaid population in Massachusetts.

STUDY DESIGN

We conducted a retrospective chart review of Spanish-speaking pregnant patients younger than 35 years of age who underwent aneuploidy serum screening at a Massachusetts community health center. The study compared the aneuploidy serum screening rates for the periods before and after May 2016 when the Massachusetts Medicaid program, MassHealth, temporarily discontinued reimbursement for the screening. Based on these rates, we developed a Markov cohort simulation model to assess the economic value of reimbursed aneuploidy screening vs nonreimbursed or limited screening. Clinical outcomes included trisomy 21, live births, and therapeutic abortions for a trisomy 21 diagnosis. Economic outcomes included discounted quality-adjusted life years and lifetime medical costs, net health benefit, and incremental cost-effectiveness ratios.

RESULTS

Before the MassHealth policy change, 69% (55/80) of pregnant individuals selected quad or sequential screens in comparison with only 9% (10/112) who selected screens after the policy change. Traditional aneuploidy serum screening in a low-risk (aged <35 years) Hispanic population was considered to be cost-saving (ie, led to lower incremental costs and higher incremental benefits when compared with nonreimbursed or limited screening).

CONCLUSION

From a United States healthcare payer perspective, aneuploidy serum screening for Hispanic pregnant individuals under 35 years of age is economically advantageous when compared with limited screening.

Effect of Present-on-Admission (POA) Reporting Accuracy on Hospital Performance Assessments Using Risk-Adjusted Mortality

OBJECTIVE

To evaluate how the accuracy of present-on-admission (POA) reporting affects hospital 30-day acute myocardial infarction (AMI) mortality assessments.

DATA SOURCES

A total of 2005 California patient discharge data (PDD) and vital statistics death files.

STUDY DESIGN

We compared hospital performance rankings using an established model assessing hospital performance for AMI with (1) a model incorporating POA indicators of whether a secondary condition was a comorbidity or a complication of care, and (2) a simulation analysis that factored POA indicator accuracy into the hospital performance assessment. For each simulation, we changed POA indicators for six major acute risk factors of AMI mortality. The probability of POA being changed depended on patient and hospital characteristics.

PRINCIPAL FINDINGS

Comparing the performance rankings of 268 hospitals using the established model with that using the POA indicator, 67 hospitals' (25 percent) rank differed by ≥10 percent. POA reporting inaccuracy due to overreporting and underreporting had little additional impact; POA overreporting contributed to 4 percent of hospitals' difference in rank compared to the POA model and POA underreporting contributed to <1 percent difference.

CONCLUSION

Incorporating POA indicators into risk-adjusted models of AMI care has a substantial impact on hospital rankings of performance that is not primarily attributable to inaccuracy in POA hospital reporting.

Improving and measuring inpatient documentation of medical care within the MS-DRG system: education, monitoring, and normalized case mix index

Documentation of the care delivered to hospitalized patients is a ubiquitous and important aspect of medical care. The majority of references to documentation and coding are based on the Centers for Medicare and Medicaid Services (CMS) Medicare Severity Diagnosis Related Group (MS-DRG) inpatient prospective payment system (IPPS). We educated the members of a clinical care team in a single department (neurosurgery) at our hospital. We measured subsequent documentation improvements in a simple, meaningful, and reproducible fashion. We created a new metric to measure documentation, termed the "normalized case mix index," that allows comparison of hospitalizations across multiple unrelated MS-DRG groups. Compared to one year earlier, the traditional case mix index, normalized case mix index, severity of illness, and risk of mortality increased one year after the educational intervention. We encourage other organizations to implement and systematically monitor documentation improvement efforts when attempting to determine the accuracy and quality of documentation achieved.

Engaging residents and fellows to improve institution-wide quality: the first six years of a novel financial incentive program

PURPOSE

Teaching hospitals strive to engage physicians in quality improvement (QI), and graduate medical education (GME) programs must promote trainee competence in systems-based practice (SBP). The authors developed a QI incentive program that engages residents and fellows, providing them with financial incentives to improve quality while simultaneously gaining SBP experience. In this study, they describe and evaluate success in meeting goals set during the program's first six years.

METHOD

During fiscal years (FYs) 2007-2012, QI project goals for all or specific training programs were set collaboratively with residents and fellows at the University of California, San Francisco (UCSF). Data were collected from administrative databases, via chart abstraction, or through independently designed techniques.

RESULTS

Approximately 5,275 residents and fellows were eligible and participated in the program. A total of 55 projects were completed. Among the 18 all-program projects, goals were achieved for 11 (61%) in three domains: patient satisfaction, quality/safety, and operation/utilization. Among the 37 program-specific projects, goals were achieved for 28 (76%) in four categories: patient-level interventions, enhanced communication, workflow improvements, and effective documentation. Residents and fellows earned an average of $800 in bonuses/FY for achieving these goals.

CONCLUSIONS

Thousands of residents and fellows across disciplines participated in real-life, real-time QI during the program's first six years. Participation provided an experience that may promote SBP competence and resulted in improved quality of care across the UCSF Medical Center. Similar programs may assist teaching hospitals and GME programs in meeting current and future QI and training mandates.

The Medicare policy of payment adjustment for health care-associated infections: perspectives on potential unintended consequences

In 2008, the Centers for Medicare & Medicaid Services introduced a new policy to adjust payment to hospitals for health care-associated infections (HAIs) not present on admission. Interviews with 36 hospital infection preventionists across the United States explored the perspectives of these key stakeholders on the potential unintended consequences of the current policy. Responses were analyzed using an iterative coding process where themes were developed from the data. Participants' descriptions of unintended impacts of the policy centered around three themes. Results suggest the policy has focused more attention on targeted HAIs and has affected hospital staff; relatively fewer systems changes have ensued. Some consequences of the policy, such as infection preventionists having less time to devote to HAIs other than those in the policy or having less time to implement prevention activities, may have undesirable effects on HAI rates if hospitals do not recognize and react to potential time and resource gaps.

The CMS Value-Based Purchasing Program: Making Sense of the Regulations and Implications for Health System Pharmacy

The Director's Forum series is designed to guide pharmacy leaders in establishing patient-centered services in hospitals and health systems. This article focuses on the Center for Medicare & Medicaid Service's (CMS) Value-Based Purchasing (VBP) program for hospitals. VBP links Medicare payments to the quality performance of acute care hospitals paid under the Inpatient Prospective Payment System (IPPS), for patient assigned to various diagnosis-related groups (DRGs). It is essential that pharmacy directors understand the implications of the VBP program and the subsequent opportunity that it creates for pharmacy. To take full advantage of the program, adjustments will need to be made in staffing, skill mix, and ultimately the design of the pharmacy practice model.

The accuracy of present-on-admission reporting in administrative data

OBJECTIVE

To test the accuracy of reporting present-on-admission (POA) and to assess whether POA reporting accuracy differs by hospital characteristics.

DATA SOURCES

We performed an audit of POA reporting of secondary diagnoses in 1,059 medical records from 48 California hospitals.

STUDY DESIGN

We used patient discharge data (PDD) to select records with secondary diagnoses that are powerful predictors of mortality and could potentially represent comorbidities or complications among patients who either had a primary procedure of a percutaneous transluminal coronary angioplasty or a primary diagnosis of acute myocardial infarction, community-acquired pneumonia, or congestive heart failure. We modeled the relationship between secondary diagnoses POA reporting accuracy (over-reporting and under-reporting) and hospital characteristics.

DATA COLLECTION

We created a gold standard from blind reabstraction of the medical records and compared the accuracy of the PDD against the gold standard.

PRINCIPAL FINDINGS

The PDD and gold standard agreed on POA reporting in 74.3 percent of records, with 13.7 percent over-reporting and 11.9 percent under-reporting. For-profit hospitals tended to overcode secondary diagnoses as present on admission (odds ratios [OR] 1.96; 95 percent confidence interval [CI] 1.11, 3.44), whereas teaching hospitals tended to undercode secondary diagnoses as present on admission (OR 2.61; 95 percent CI 1.36, 5.03).

CONCLUSIONS

POA reporting of secondary diagnoses is moderately accurate but varies by hospitals. Steps should be taken to improve POA reporting accuracy before using POA in hospital assessments tied to payments.