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Quality Improvement Fundamentals and MIPS

Stethoscope and money

Connecting basic quality improvement (QI) work to new government programs can be a bit of work. A case in point is the Merit-based Incentive Payment System (MIPS), one of two payment tracks for Medicare Part B clinicians under the Quality Payment Program.

If your practice takes part in an Advanced Alternative Payment Model (AAPM), you don’t necessarily need to participate in MIPS unless your AAPM requires it. Most AAPMs do require participation in the same requirements of the MIPS program. So, in most cases you’ll need to participate in MIPS (or prescribed components of it for your AAPM) in 2018 to avoid a negative payment adjustment. And starting in 2020, the cost of care you provide will affect the way you get paid for Medicare services, based on your MIPS performance in 2018.

The four variables of MIPS―Costs, Quality Reporting, Advancing Care Information and Improvement Activities―will all count toward a performance score that can swing your payment as much as 5 percent downward or upward, depending on your performance. Costs will account for only 10 percent of your overall performance score in 2018 (for 2020 implementation), but will increase to 30 percent of your score in 2019 (for 2021 implementation), as it affects your payment fee schedule from Medicare.

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What I’m Grateful for This Holiday Season

family at the park

Three-and-half years ago, my brother-in-law was diagnosed with Amyotrophic lateral sclerosis (ALS) also known as Lou Gherig’s disease. ALS is a progressive, terminal neurological disease.

Believing that laughter is always the best medicine, we made a lot of jokes, including that I, his sister-in-law, was eventually going to kill him (my initials are ALS, Amy Lynn Schmidt).

Over the past three years, ALS has slowly robbed Chris of his ability to walk, feed himself and breathe independently, and yet he has managed to make the most of every day, even from his wheelchair – cruising along the Italian coast to celebrate his 25th wedding anniversary; fishing in Sunnyside with his two sons; and rolling up to the bar at his favorite watering hole to drink as much craft beer as my sister will allow. His mantra has been “do what you can do.” And he’s done more than most.

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Something Is a Foot

Holding hands

In the last month, I’ve suddenly become very familiar with a podiatrist. Two of my sons and my wife needed to be seen for three different health concerns within three weeks, which included outpatient surgery for my wife. All of these visits provided a very intimate picture of our health care system for me, and I was reminded of why HealthInsight is doing the work we are doing. Although, I’ll admit that oftentimes I feel removed from our endeavors by being so focused on the technology and related processes supporting our work, the past few weeks have been a reminder of how closely I’m tied to this work.

Here are a few of my experiences:

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Resiliency: What is it anyway? And Where Can I Find Some?

Hiker at summit

It is pretty difficult to work in the health care setting without hearing about the plague that has infested the majority of the workforce: burnout. The pressures of caregiving, budgets, bottom lines, quality scores and regulatory burden have been named as a few of the causes. As leaders in health care, we have acknowledged the illness and pinpointed the cause of burnout, but continue to struggle to find a cure.

The impact of burnout is widespread. A 2013 study by the Luican Leape Institute at the National Patient Safety Foundation found health care workforce injuries are 30 times greater than other industries, 60 percent of physicians surveyed were considering leaving practices, 70 percent knew a physician who left due to poor morale and 37 percent of newly licensed registered nurses were thinking of leaving their job. It seems that in our efforts to transform the health care system, we have neglected the very people carrying out the transformation. In the search for relief, many health care organizations have worked on building the resiliency of the workforce. Resiliency is the ability of people to cope with stress or crisis, and then rebound quickly.

Sheryl Sandburg, Facebook executive and author of Lean In, recently found herself in desperate search for resiliency when her husband died suddenly while they were vacationing out of the country. In her latest book, Option B: Facing Adversity, Building Resilience, and Finding Joy, she describes the first few fragile days and months following his death, and her quest for a way to live through the pain. She thought that “resilience was the capacity to endure pain” and wanted to know how much resilience she had. However, she discovered that our amount of resilience isn’t fixed, and we should instead ask how we can become resilient. “Resilience is the strength and speed of our response to adversity—and we can build it. It isn’t about having a backbone. It’s about strengthening the muscles around our backbone.”

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What if we run out of antibiotics?

microscope

Antibiotics were miracle drugs in the 1930s 40s and 50s. After Scottish researcher Sir Alexander Fleming accidentally discovered penicillin in 1928, he was quoted as saying, “One sometimes finds what one is not looking for. When I woke up just after dawn on Sept. 28, 1928, I certainly didn’t plan to revolutionize all medicine by discovering the world’s first antibiotic, or bacteria killer. But I guess that was exactly what I did.” Previously life-threatening diseases became treatable and many new drugs were developed between 1950 and 1970, making this the “golden era” of antibiotics.

Unfortunately, Alexander Fleming’s warning that “overuse may cause mutant bacteria” also started to come true around this time, and, as antibiotics were used more and more both in humans and in animals, even antibiotics developed to treat resistant strains became ineffective. Coupled with the fact that drug companies may not be as focused on developing short-term medicines than those needed for life, new drug development slowed substantially, coming almost to a halt in 2010.

So, what does this mean for us? Will stories about antibiotic resistance become more typical, like one from a HealthInsight staff member who has shared about a very scary time a few years ago when she had an infection that was resistant to all oral antibiotics? This infection required two rounds of intravenous antibiotics and spurred the fear that they may not work. Are stories like the woman in Reno, Nevada, who died in early 2017 of a resistant infection that no U.S. antibiotic could treat going to be more commonplace? I truly hope not. I sincerely believe that the global effort around preserving antibiotics and reducing resistance will succeed. A national action plan was initiated in 2015 in response to an executive order from President Obama. This action plan includes goals to accelerate the development of new drugs and diagnostic tests as well as to increase surveillance of infections and work together with International partners to slow resistance.

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“Just the Facts, Ma’am”

In the 1950s, a popular, long-running TV series titled “DRAGNET” featured two, serious-as-a-heart-attack Los Angeles Police Department detectives: Sergeant Joe Friday and his partner, Officer Bill Gannon. Every week they set out to investigate and solve serious crimes in the big city. After viewing one episode, you could tell that neither of these two, steely, uber-committed police officers had a single political bone in their respective bodies. They were all about getting to and understanding the facts—the truth. And, with the facts and the full truth, they could then do the hard work to solve every otherwise difficult and confounding case.

In our modern times of partisan politics, social media and the daily news cycle, there is often very little focus on objectively examining the facts, on finding common ground and on solving many of the great problems of our day. However, the greatness of our country is demonstrated whenever we and our leaders find ways to unite and to gain principled consensus; to find the best, most practical, if imperfect, solutions to the challenging issues of our day.

So, here are some hard-to-ignore facts on an important and daunting challenge: Federal spending on entitlement programs (Social Security, Medicare, Medicaid, the Affordable Care Act) continues to grow at ever higher rates—as a percent of our gross domestic product (GDP), and as a portion of federal revenues. Also, the cost of interest payments on the national debt will rise precipitously over the coming years as large deficits continue to accrue and as artificially-low interest rates rise to market levels. Eventually, this predictable deficit spending will overwhelm the federal budget and lead to a fiscal crisis—if our national leaders fail to control the growth of spending and the cost-drivers within the system.

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The Power of Prevention

Mom kissing baby

A few years ago, I watched as a childhood friend was diagnosed with diabetes and then multiple other related co-morbidities in rapid succession. It has affected every aspect of her life and was caught much later than it should have been, exasperated by years of lacking access to health insurance and preventative care. As her friend, I knew on some level for that she was at risk of developing a chronic condition and did my best to support her, but was unsure how to help her change her circumstances. I’ve worked in a health related field for most of my career, but this experience has further driven me to want to advance prevention and understand what people truly need to stay healthy.

An alarming 1 out of 3 adults has pre-diabetes. And of those, 15-30 percent will develop Type 2 diabetes within five years. Not only is diabetes emotionally, physically and financially costly for individuals and their families, it accounts for 23 percent of total health care costs annually in the United States and is highly associated with heart disease, which is the leading cause of death worldwide.

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Cost of Medications

Needle and Pills

Over the past year we’ve heard about terrible price increases in the EpiPen® and how horrible this skyrocketing was because it’s a lifesaving medication. There’s no doubt that the EpiPen is lifesaving, but what qualifies a medication as lifesaving? Any medication that controls an acute or chronic medical problem is lifesaving.

As an endocrinologist, to me the most common lifesaving medication is insulin. Let’s look at what has happened due to the costs of insulin. Retail costs of newer insulins can cost up to $500 or even $600 per month. Older ones can cost about half that. And copays can range from $40 to $150. Patients sometimes tell to their physicians that they’ve stopped their insulin because they can’t afford it. In fact, some have reported that they stopped their insulins and ended up in the hospital, but their hospital copay was less than their prescriptions. Older patients have said that they stopped their insulins when they hit the “doughnut hole” in Medicare.

If you go on the Good Rx website, you’ll find that you can get regular or NPH insulin (an intermediate insulin) for around $27 each. I’ve sent patients in two different states to Wal-Mart pharmacies to buy these insulins, and they have all been told that Wal-Mart doesn’t have anything comparable to these prices. Many pharmaceutical companies offer discount cards that enable patients to purchase a month’s supply for $10 to $25 for up to 12 months. But, to get these cards, you must meet eligibility requirements. And if you’re on Medicare, Medicaid, Tricare, VA, Department of Defense or similarly federally or state-funded programs, you won’t qualify. One bright spot is that Federal Employees Health Benefits Program members do qualify.

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Celebrating Achievements in Health Care Quality

Doctors and Nurses

HealthInsight is acutely aware of the challenges health care providers face in improving the quality of care. We work hard with our community partners to advance quality initiatives that sometimes seem to take a step back for every two steps forward. In the midst of our labors, it behooves us to pause now and then to celebrate our successes.

Since 2004, HealthInsight’s Quality Award program has recognized Medicare-certified providers who demonstrate excellent performance on publicly reported quality-of-care measures. We created this program to encourage providers to invest in quality and systems improvement, and to promote transparency in measures of safety, quality and patient experience of care.

Public recognition of top-performing providers not only motivates other providers to improve their performance, but gives consumers information they can use to make choices about their own care. Our awards also tie into the nationwide movement toward paying providers for the quality of care they deliver.

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Pitfalls of Analytical Product Development and How to Escape Them

Data Analytics

Our health care analysts build data-driven products (dashboards, reports, etc.), and they think through all of the technical implementation steps required to make these products successful. The next step determines the success of the product: pinpointing and avoiding the potential pitfalls that can undermine its usefulness. These pitfalls include:

  • Failure to understand what we really mean by "business intelligence"
  • Poor understanding of the users of our product and their needs
  • Poor data management

Often data sources look like a dangerous cocktail of social determinants of health coupled with genetic, environmental and clinical data with other information thrown in. Finding a meaningful way to manage these data and capitalize on the value of the information can be challenging.

Let’s look at the end user of our analytical products – the provider. The volume, variety and velocity of available information can far exceed any professional’s abilities to process and interpret. For example, our Partnership to Advance Tribal Health (PATH) participating hospitals are bombarded and confused by multiple layers of mandatory reporting and dashboards provided by local area offices, their Medicare Quality Improvement Networks, their Hospital Improvement Innovation Network organization, tribal epidemiology centers, state departments of health and many more organizations.

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