CMS’ current focus on reducing preventable rehospitalizations within 30 days of discharge represents a timely, strategic use of performance measurement to address an evident problem where there are demonstrated approaches to achieve successful improvement [6]. Physicians and hospital clinical staff, if not necessarily hospital financial officers, generally have responded quite positively to the challenge of reducing preventable readmissions.
CMS has complemented the statutory mandate to provide financial incentives to hospitals to reduce readmission rates by developing new service codes in the Medicare physician fee schedule that provide payment to community physicians to support their enhanced role in assuring better patient transitions out of the hospital in order to reduce the likelihood of readmission [7]. CMS recently announced that after hovering between 18.5 percent and 19.5 percent for the past five years, the 30-day all-cause readmission rate for Medicare beneficiaries dropped to 17.8 percent in the final quarter of 2012 [8], simplying some early success with efforts to use performance measures as part of a broad quality improvement approach to improve a discrete and important quality and cost problem.
However, this Timely Analysis of Immediate Health Policy Issues 3“CMS’ current value-based purchasing efforts, requiring reporting on a raft of measures of varying usefulness and validity, should be replaced with the kind of strategic approach used in the national effort to reduce bloodstream infections.”approach is not without controversy.
Improvements have been modest, and some suggest that readmission rates are often outside the hospital’s control, so CMS’ new policy unfairly penalizes hospitals that treat patients who are the sickest [9]. And while readmission in surgical patients is largely related to preventable complications, readmissions in medical patients can be related to socioeconomic status. Also, some have questioned the accuracy of CMS’ seemingly straightforward readmission rate measure, finding that some hospitals reduce both admissions and readmissions—a desirable result—yet do not impact the readmission rate calculation [10]. And one of this paper’s authors (R. Berenson) has suggested a very different payment model that would reward hospital improvement rather than absolute performance, thereby addressing the reality that hospitals’ abilities to influence readmission rates do vary by factors outstside of their control [11].
We consider the current controversy around implementation of a readmissions penalty to be a healthy debate. Because the purpose for which the penalty was designed is so important, scrutiny and vigorous discussion can lead to improvements to CMS’ payment policy and performance measures to address what remains an unacceptable failure in U.S. health care delivery. There clearly is a tension between getting the measures absolutely right and achieving a “good enough” status that can produce quality improvement. In the words of Jonathan Blum, deputy administrator and director for the Center of Medicare at CMS, “It’s a very traumatic event to go back to the hospital. I’m personally comfortable with some imprecision to our measures [12].”
With the growing evidence that Congress’s “value-based purchasing” approach to measuring and rewarding hospitals (Congress’s term for pay-forperformance) only marginally improves patient outcomes, and possibly diverts attention from doing the hard work of making culture and work process improvements that actually would produce improved outcomes, Congress should refocus its directives to CMS to emphasize improving specific quality deficiencies—relying more on promoting collaborative quality improvement activities and new payment approaches that incorporate performance measures than on public reporting and pay-for-performance per se. As an illustration, the nuclear industry has a robust approach to improving quality using peer-to-peer review, validated tools, and a focus on learning rather than judging [13].
CMS on its own created the Partnership for Patients, a public/private partnership to improve the quality, safety, and affordability of health care for all Americans. The initiative promotes active collaboration by physicians, nurses, and other hospital personnel, as well as employers, patients and their advocates, and federal and state governments to address tangible problems where approaches to quality improvement to improve outcomes exist but need broad-based adoption. Specifically, CMS is funding 26 hospital engagement networks to allow 3,700 hospitals to share best practices, and funding 82 sites to provide care transitions services to Medicare beneficiaries leaving the hospital through the agency’s Community-Based Care Transitions Program; it is also encouraging patient engagement through both of these efforts [14]. The Partnership for Patients began in 2011, under the guidance of then acting CMS Administrator, Donald Berwick, and has targeted two basic areas for quality improvement with specific measureable outcome objectives [15]:
1. Making Care Safer. By the end of 2013, preventable hospital-acquired conditions would decrease by 40 percent compared to 2010.
2. Improving Care Transitions. By the end of 2013, preventable complications during transition from one care setting to another would be decreased so that all hospital readmissions would be reduced by 20 percent compared to 2010.
Unfortunately, this effort started without validated performance measures and currently lacks valid performance measures for most of the conditions. As a result, it will be exceedingly difficult to evaluate whether this program improved quality or safety for patients. Given the significant public investment in this program, rigorous evaluation should be a requirement. A successful model of the strategic use of measures to accomplish substantial quality improvement can be found in recent efforts to reduce central line-associated blood stream infections (CLABSI) (see appendix).
In this case, the primary motivation for physicians, nurses, and other hospital staff to participate in this activity was intrinsic—to reduce preventable mortality and morbidity caused by infections. One of the authors (P. Pronovost) who was instrumental in developing and leading the CLABSI-reduction programs believes that public reporting of infection rates by states, Consumer Reports, the Commonwealth Fund, and, later, CMS had a generally positive effect on stimulating interest and action at senior levels of hospital management. Also contributing were the efforts of the Joint Commission with its national patient safety goals, and the Center for Disease Control and Prevention’s (CDC) National Healthcare Safety Network and their work with state health departments to shine a spotlight on a problem that had a solution. The CDC recently reported that central-line bloodstream infections dropped by 41 percent between 2008 and 2011 [16].
Many opportunities for broad-based collaborations to improve hospital quality exist. CMS’ current valuebased purchasing efforts, requiring reporting on a raft of measures of varying usefulness and validity, should be replaced with the kind of strategic approach used in the national effort to reduce bloodstream infections.
Similarly, the current approach to improving the quality of care provided by physicians in Medicare needs to be reconsidered. Many physicians believe quality reporting on a few measures is being promoted as an end in itself, whether or not the particular measures chosen represent high priority for improvement, can accurately reflect the physician’s actual quality of care, or are associated with meaningful patient outcomes. Drawing inferences about a physician’s quality using a few measures peripheral to the physician’s core professional activities may well be misleading and a diversion from the opportunity to engage physicians in substantive quality improvement activities.
Here, again, policy-makers should be more strategic, focusing on clinical areas where measures are meaningful and valid, and where concerted multi-party collaboration could materially improve the health of the population. With this approach, it is likely that not all physicians in Medicare would be routinely measured; but much of what the public wants to know about physician competence and performance cannot be measured using the currently available measure sets. Strategies that work through peer assessment and fostering professionalism may also provide promising opportunities to improve quality and safety.
Observing the lack of “high leverage” processes of surgical care, particularly those specific to particular procedures, experts on surgical quality have suggested that surgeons be encouraged and supported to participate in surgical learning collaborative activities, with no reporting or rewards for individual performance. [17]. Building on this suggestion, a more strategic approach would judge the effectiveness of care in terms of collective improvements in outcomes—on clinical quality, patient experience, and cost. Measurement would be integrated into quality improvement initiatives, such as those led by Regional Health Improvement Collaboratives [18], national medical specialty societies [19], national specialty boards [20], and accountable care organizations (ACOs) as they come online.
In short, Congress should allow CMS greater flexibility to provide physician incentives to actively participate in meaningful quality improvement collaboratives as an alternative or a complement to routine reporting and public reporting on a handful of quality measures.
Robert A. Berenson, MD is an institute fellow at the Urban Institute.
Peter J. Pronovost, MD, PhD is the director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins, as well as Johns Hopkins Medicine’s senior vice president for patient safety and quality.
Harlan M. Krumholz, MD, is the director of the Yale-New Haven Hospital Center for Outcomes Research and Evaluation, director of the Robert Wood Johnson Foundation Clinical Scholars program at Yale University, and the Harold H. Hines, Jr. professor of cardiology, investigative medicine, and public health.
The authors thank Lawrence Casalino, MD, PhD, chief of the Division of Outcomes and Effectiveness Research and an associate professor at Weill Cornell Medical College, and Andrea Ducas, MPH and Anne Weiss, MPP of the Robert Wood Johnson Foundation for their helpful comments on this paper. This research was funded by theRobert Wood Johnson Foundation, where the report was originally published.
Notes
6. Jencks SF, Williams MV, Coleman EA. “Rehospitalizations Among patients in the Medicare Fee-for-Service Program.” New England Journal of Medicine, 360:1418-1428, 2009 [Erratum, New England Journal of Medicine, 364:1582, 2011]; Chollet D, Barrett A and Lake T. Reducing Hospital Readmissions in New York State: A Simulation Analysis of Alternative Payment Incentives. Princeton, NJ: Mathematica Policy Research, 2011, http://nyshealthfoundation.org/uploads/resources/reducing-hospital-readmissions-payment-incentives-september-2011.pdf (accessed April 2013).
7. Bindman AB, Blum JD and Kronick R. “Medicare’s Transitional Care Payment—A Step toward the Medical Home.” New England Journal of Medicine, 368(8): 692-694, 2013.
8. Blum J. “Statement of Jonathan Blum, Acting Principal Deputy Administrator and Director, Center for Medicare, Centers for Medicare & Medicaid Services, On Delivery System Reform: Progress Report from CMS, Before the U.S. Senate Finance Committee.” Feb. 28, 2013, www.finance.senate.gov/imo/media/doc/CMS%20Delivery%20System%20Reform%20Testimony%202.28.13%20(J.%20Blum).pdf (accessed April 2013).
9. Abelson R, “Hospitals Question Medicare Rules on Readmissions,” New York Times, March 29, 2013.
10. Brock J, Mitchell J, Irby K, et al. “Association Between Quality Improvement for Care Transitions in Communities and Rehospitalizations Among Medicare Beneficiaries.” Journal of the American Medical Association, 309(4): 381-391, 2013.
11. Berenson RA, Paulus RA and Kalman NS. “Medicare’s Readmissions-Reduction Program—A Positive Alternative.” New England Journal of Medicine, 366: 1364-1366, 2012.
12. Abelson, 2013.
13. Pronovost PJ and Hudson DW. “Improving Healthcare Quality Through Organisational Peer-to-Peer Assessment: Lessons from the Nuclear Power Industry.” BMJ Quality and Safety, 21(10):872-875, 2012.
14. About the Partnership for Patients. Baltimore: Centers for Medicare and Medicaid Services, http://partnershipforpatients.cms.gov/about-thepartnership/aboutthepartnershipforpatients.html (accessed April 2013).
15. Partnership for Patients. Baltimore: Centers for Medicare and Medicaid Services, http://partnershipforpatients.cms.gov/about-the-partnership/what-is-thepartnership-about/lpwhat-the-partnership-is-about.html (accessed April 2013).
16. 2011 National and State Healthcare-associated Infections Standardized Infection Ratio Report. Atlanta: Centers for Disease Control and Prevention, www.cdc.gov/hai/national-annual-sir/index.html (accessed April 2013).
17. Birkmeyer NJO and Birkmeyer JD. “Strategies for Improving Surgical Quality—Should Payers Reward Excellence or Effort?” New England Journal of Medicine, 354(8): 864-870, 2006.
18. Roles of Regional Health Improvement Collaboratives: Measuring Healthcare Performance. Pittsburgh, PA: Network for Regional Healthcare Improvement, www.nrhi.org/performancemeasurement.html (accessed April 2013).
19. Ferris TG, Vogeli C, Marder J, et al. “Physician Specialty Societies And The Development Of Physician Performance Measures.” Health Affairs, 26(6): 1712-1719, 2007.
20. Iglehart JK and Baron RB. “Ensuring Physicians’ Competence — Is Maintenance of Certification the Answer?” New England Journal of Medicine, 367: 2543-2549, 2012.
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