Title: Doing Well By Doing Good: The Physician Business Case for Quality
1Doing Well By Doing Good The Physician Business
Case for Quality
- Alice G. Gosfield, Esq.
- NERVES
- April 15, 2005
2- Alice G. Gosfield, J.D.
- Alice G. Gosfield and Associates, PC
- 2309 Delancey Place
- Philadelphia, PA 19103
- (215) 735-2384
- Agosfield_at_gosfield.com
- www.gosfield.com
- www.uft-a.com
3Overview
- 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?
4- Every system is perfectly designed to achieve
the results it gets. - Donald Berwick, M.D.
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
6Todays 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
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
doesnt meet standards - Civil money penalties for quality failures
- Medical necessity, premature discharge, for
payments to reduce services -
-
8CMPs 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 -
9The 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
10Why 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 (Reinertsens Axioms)
- Explain, predict and change patient futures the
healing relationship
11Hazards to Time and Touch
- Irrelevant documentation of many types
- E M codes false claims exposure Medical
necessity of services Ministerial minutiae (CMNs
for DME)
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
13Time and Touch Hazards (contd)
- 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
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
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
16The 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
17P4P 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?
18- Every system is perfectly designed to achieve
the results it gets. - Donald Berwick, M.D.
19What 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
20The 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
21STEEEP
- 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
22Escaping the Rabbit Hole Five Principles
- Standardize
- Simplify
- Make Clinically Relevant
- Engage the Patients
- Fix Accountability at the Locus of Control
23Gosfields 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
24P4P compared
25Physicians 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?
26Clinical 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
27UFT-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
28 Boundaries to UFT-A
- This is not for everyone groups, virtual
groups, the good guys, the innovators - Payment approach wont 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
29Advantages
- 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
30Advantages (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
31Why 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
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
33Resources
- 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/DrPatientR
elationship.pdf -
34More 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/ar
chives/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 -
-
35More 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/medsou
th.htm)