Quality metrics are key to achieving fame and fortune as a hospitalist, according to Win Whitcomb, MD, who spoke at Internal Medicine 2014 in Orlando, Fla., in April. Dr. Whitcomb is a hospitalist and chief medical officer for Remedy Partners, a health care services company in Darien, Conn., that administers bundled payments.
It probably won't be celebrity-level fame and fortune—although Dr. Whitcomb did point out that both U.S. News & World Report and Consumer Reports publish hospital ratings—but measures are beginning to carry real money and the chance “to be publicly embarrassed or publicly made to look wonderful,” he said.
Readmissions penalties and value-based purchasing (VBP) are scheduled to affect an increasing percentage of hospitals' Medicare payments over the next few years, and hospital-acquired conditions will attract new penalties beginning in 2015. The numbers may be small right now, but they will add up.
“By the time we get to 2017, with these 3 programs, a medium-sized hospital will have $5 million at risk,” said Dr. Whitcomb.
Those numbers may frighten hospital executives, but hospitalists who provide high-value care could actually benefit, because their efforts will be essential to hospitals' financial success. “I see this as a major opportunity for hospitalists,” Dr. Whitcomb said.
Hospitalists will also be involved in CMS's new effort to evaluate and reward health care efficiency. The measure, which debuts in 2015 but will actually be based on 2013 data, compares all Medicare Part A and B spending per beneficiary from 3 days prior to a hospitalization to 30 days after discharge. “It's actually a lot like a bundled payment,” said Dr. Whitcomb.
Another change to quality measures is that they're going to begin affecting physician income, and not just as a trickle-down from hospital charges. Medicare's Value-Based Payment Modifier (VBPM) will raise or lower physician payments by 1% or 2%, starting with groups of 100 or more doctors in 2015 and including all doctors in 2017.
That's not a lot of money, Dr. Whitcomb noted, and the Physician Quality Reporting System (PQRS), on which the VBPM is based, has only lured 30% of physicians to participate. “It's been a hard program to participate in,” said Dr. Whitcomb, who showed calculations indicating that a typical hospitalist with $450,000 in annual charges would only gain about $700 in the PQRS program.
The VBPM measures relevant to hospitalists include things like prescribing antiplatelets to patients with coronary artery disease, screening for dysphagia after stroke, and treating atrial fibrillation with warfarin. “You and I can decide whether these are our picture of what a great hospitalist is or not,” said Dr. Whitcomb.
That debate is the biggest problem with quality metrics, said Dr. Whitcomb, whose talk was subtitled “The Good, the Bad and the Ugly.” Critics have charged that the qualities of hospitalists that really count—including timely diagnosis and treating complicated patients—aren't measured.
And it's clear that documentation decisions have a major impact on results. For example, concern over hospital-acquired conditions will likely drive your hospital's coding experts to flag any catheter-associated infections you note, if they haven't started already. “Think about what you write in the chart,” said Dr. Whitcomb advised.
Another challenge is the difficulty of measuring the performance of any individual physician, which there will be an increasing push to do. “Any outcome measure that's applied at the individual physician [level] is very tough to do,” Dr. Whitcomb said.
He showed the audience an example of his own Joint Commission-required Ongoing Professional Practice Examin-ation (OPPE) report, describing the statistics on it as “mysterious.” This measurement, which compares one's resource utilization and metrics like 30-day mortality to an unspecified peer group, is meant to eventually determine physician credentialing, but how that would work is “very vague right now,” he said.
Then there's patient satisfaction scoring. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores were never meant to assess satisfaction with individual physicians, and even more targeted surveying, such as that done by Press Ganey, poses problems when hospitalists are compared to other physician specialties.
According to such surveys, “Patients are least satisfied when they are on the psychiatry inpatient service. Next to that it's us,” Dr. Whitcomb said, to laughs from the audience. Patients admitted through the emergency department also have particularly low satisfaction, meaning that hospitalists are very likely to score low in across-specialty comparisons. “We really need to be compared to like physicians,” he said.
Dr. Whitcomb encouraged his audience to push their hospitals for hospitalist-specific satisfaction surveying. He also suggested they investigate the metrics they're being measured on, asking questions like “If you're being measured on a process measure, is it something that affects outcomes? If it's an outcome, is the sample size big enough to be valid?” and “Is it something you have influence over?”
In answer to that last question, it may necessary to broaden your perspective to encompass new, more expansive concepts of team care, such as accountable care organizations. “I think we have to get past that thing of ‘We have no control over it,’” said Dr. Whitcomb. “Maybe you do have control if you work as a team.”
And, finally, whether you're evaluating, reviewing, or just complaining about quality metrics, don't forget the whole reason for their existence. “Quality metrics to me don't mean all that much if we don't move past measurement to improvement,” said Dr. Whitcomb. “Isn't that the real reason why we're here? Let's not lose sight of that.”