DCMedical News: Wednesday, May 11, 2022
DCMedical News is published every day both the House and the Senate are scheduled to be in session.
THE BIG STORY Wednesday, May 11, 2022
What Do We Talk About When We Talk About Quality?
Dr. Lisa Rosenbaum attempts to reimagine the health quality industry, ensnared in reimbursement-related and often clinically irrelevant metrics. In a three-part series in The New England Journal of Medicine (here, here and here), she sets the stage through the eyes of quality industry founder Donald Berwick.
She writes, "Acknowledging that most health care workers want to do right by patients, Berwick recognized that blaming workers for factors beyond their control quashes goodwill and encourages cheating. This insight accords with a foundational principle of the QI movement: most quality lapses reflect a faulty system rather than faulty people. To improve quality, we must fix the system. Some 30 years later, however, the fix is itself a massive system . . . QI is no longer just about being better, but about documenting improvement to maximize payment. An entire industry has arisen to support the optimization and demonstration of performance."
The cost of this pursuit? "Data from the National Academy of Medicine suggest that health systems each employ 50 to 100 people for $3.5 million to $12 million per year to support measurement efforts. Small practices bear the greatest relative costs. One 2016 study found that practices spend about $40,000 per physician per year to meet quality-documentation requirements, for an estimated total of $15.4 billion per year. Financial costs aside, if good care is the goal, the greatest cost of all this activity may be wasted time. The 2016 study found that the average physician spent 2.6 hours per week on QI documentation."
Is quality improving? "It's hard to know," Dr. Rosenbaum writes. More in tomorrow's edition of DCMN.
DOCTORS, NURSES AND OTHER HEALTH PROFESSIONALS
Pediatric Nurse Practitioner Roles Defined, Discussed
The interplay of licensure, accreditation, certification and employer expectations and roles—the standards for pediatric NPs, discussed here, in The Journal for Nurse Practitioners. "Approximately 325,000 NPs are licensed in the US, but only 21,000 are pediatric-focused NPs, with 1,000 new pediatric nurse practitioners (PNPs) licensed yearly. The education of PNPs is to prepare them to care for patients from birth to 21 years of age, providing anticipatory guidance, provision of immunizations, education and counseling, urgent care visits, wellness care, and/or managing acute or chronic health conditions. PNPs have 2 defined roles for which they can be certified (i.e., primary care and acute care), and some PNPs are dual certified to practice in both of these settings." And more in this article, NP history, background, discussion of the APRN consensus model.
Alcohol Tops in Volume of Inpatient Stays for Substance Abuse Treatment
AHRQ's H-CUP project reports (here) on examination of substance abuse treatments over three years. The report notes that "7 percent of individuals aged 12 years or older reported having a substance use disorder (SUD) in the past year, and 21 percent of them received substance use treatment. SUDs are a common reason for hospitalization in the United States. Alcohol- and opioid-related disorders rank in the top 100 principal diagnoses for inpatient stays."
"State rates of inpatient stays for the five leading substance use disorders (SUDs) varied across the 38 States included in this Statistical Brief. State rates per 100,000 population for: Alcohol-related disorders varied sixfold, from 37.7 to 227.8. Opioid-related disorders varied thirty-one-fold (2.6 to 81.3). Stimulant-related disorders varied twenty-seven-fold (1.5 to 40.8). Sedative-related disorders varied sevenfold (1.2 to 7.9). Cannabis-related disorders varied tenfold (0.7 to 7.0)."
Regional variation: "hot spots of inpatient stays for: Alcohol-related disorders were concentrated in the Midwest, parts of Appalachia, Nevada, and Rhode Island. Opioid-related disorders were concentrated in Appalachia and New Jersey. Stimulant-related disorders were concentrated in the Midwest, the South, and parts of Appalachia. Sedative-related disorders were in Appalachia. Cannabis-related disorders occurred in all of Mississippi and parts of other southern States."
"A pattern of high rates of stays existed for all five leading SUDs in parts of the Mississippi River and/or Appalachia."
HOSPITALS AND OTHER HEALTH CARE FACILITIES
Proposed IPPS Rule for FY 2023 Published in Federal Register, Clock Begins
Arguably the most important single document in health policy each year, the "proposed rule" for the hospital Inpatient Prospective Payment System (and a variety of more or less related programs) for FY 2023 was published in Tuesday's Federal Register, here. Comments are due by June 17. The final rule, typically published in late summer, would be effective October 1, 2022.
The introduction to the proposed rule announces that "This proposed rule would: Revise the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs of acute care hospitals; make changes relating to Medicare graduate medical education (GME) for teaching hospitals; update the payment policies and the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs). In addition it would establish new requirements and revise existing requirements for eligible hospitals and critical access hospitals (CAHs) participating in the Medicare Promoting Interoperability Program; provide estimated and newly established performance standards for the Hospital Value-Based Purchasing (VBP) Program; and propose updated policies for the Hospital Readmissions Reduction Program, Hospital Inpatient Quality Reporting (IQR) Program, Hospital VBP Program, Hospital-Acquired Condition (HAC) Reduction Program, PPS-Exempt Cancer Hospital Reporting (PCHQR) Program, and the Long-Term Care Hospital Quality Reporting Program (LTCH QRP). It would also revise the hospital and critical access hospital (CAH) conditions of participation (CoPs) for infection prevention and control and antibiotic stewardship programs."
Early comment has included HFMA notes (here) on (1) ten additional "quality" measures, including one on health equity; and (2) suppression or refinement of some value and quality measure programs "to ensure that hospitals won’t face [financial] penalties."
DCMN will discuss at least one feature of the proposed rule in each edition published prior to June 17.
MEDICARE, MEDICAID AND COMMERCIAL HEALTH INSURANCE
Rural Areas Benefit From ARPA Marketplace Features
The Urban Institute reports (here) that enhanced premium subsidies of the American Rescue Plan Act provide support in rural areas. The explanation, "The American Rescue Plan Act (ARPA) significantly expanded the Affordable Care Act’s (ACA) advanced premium tax credits, or premium subsidies. The ACA provides two forms of financial assistance to Marketplace nongroup insurance enrollees: capping household premium contributions as a percentage of income (with more generous assistance for those with lower incomes) and lowering out-of-pocket costs such as deductibles, copayments, coinsurance, and out-of-pocket maximums in the form of cost-sharing reductions. Because of the structure of premium assistance, people living in areas of the country with the highest premiums see the greatest benefit from ARPA subsidies—and residents of rural areas are more likely to see higher insurance premiums."
READINGS & REFERENCES
Select Coronavirus Public Health Resources and References may be found here. The JAMA Patient Page explains the current status of oral anti-viral medications for COVID-19, here.
2022 CQ Congressional Calendar here.
PUBLICATION SCHEDULE FOR DCMEDICAL NEWS
May 12, 13, 16, 17, 18, 19
June 7, 8, 9, 10, 13, 14, 15, 16, 21, 22, 23, 24
July 12, 13, 14, 15, 18, 19, 20, 21, 26, 27, 28, 29
August, Congress adjourned, no issues
Notes to Fred Hyde, MD, JD, MBA, news@dcmedicalnews.org