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

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Title: 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

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

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?

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

6
Todays 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

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

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

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 (Reinertsens Axioms)
  • Explain, predict and change patient futures the
    healing relationship

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)

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

13
Time 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

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

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?

18
  • Every system is perfectly designed to achieve
    the results it gets.
  • Donald Berwick, M.D.

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

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

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

22
Escaping the Rabbit Hole Five Principles
  • Standardize
  • Simplify
  • Make Clinically Relevant
  • Engage the Patients
  • Fix Accountability at the Locus of Control

23
Gosfields 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

24
P4P compared
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?

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

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

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

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

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

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

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

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/DrPatientR
    elationship.pdf

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/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

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/medsou
    th.htm)
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