Proceed with Caution When it Comes to CT Scans

Low back pain affects three-quarters of all adults at some point. It is one of the most common reasons for seeking health care services—but it can also lead to one of the most misused forms of discovery: diagnostic imaging.

Diagnostic imaging, such as X-rays, MRIs and CT scans, are often used to aid diagnosis and help patients avoid exploratory surgery. That’s a good thing, right? Maybe, and maybe not. CT scans are used lavishly—a recent Kaiser Health News (KHN) article states that doctors no longer use them only when necessary. Researchers at the University of California, found that many people receive CT scans to check out injuries that don’t appear to be serious. Each CT scan exposes a patient to radiation, and so this ubiquitous diagnostic tool presents its own risks.

One CT scan contains about 10 millisieverts (mSv) of radiation, which equates to roughly 200 chest X-rays or 1,500 dental X-rays. CT scans’ ionizing radiation can damage DNA and cause cancer.

Scan overuse led to many national campaigns like Image Wisely, Image Gently and Choosing Wisely, which seek to educate patients and doctors about unnecessary tests, such as CT scans for headaches or back pain.

At Driving For Quality Care, we recognize the risks involved in using CT scans too much and too often. In fact, our HEDIS measure, Use of Imaging Studies for Low Back Pain, addresses it specifically. Through awareness—and measurement—of the abundancy of diagnostic imaging, health plans can identify problems and improve performance.

Our 2015 State of Healthcare Quality Report found that almost 75 percent of adults 18–50 years of age in commercial PPO plans did not have an imaging study (plain X-ray, MRI or CT scan) after a diagnosis. That’s great, but it means 25 percent received imaging studies that might have been unnecessary.

A patient facing multiple CT scans was quoted in the KHN article as saying, “I’m learning to ask a lot more questions.” So should we all! Patients and doctors should make it a priority to ask questions, especially when a practice or service is just “how it’s done.” Asking questions is how we’ll make 75 percent into 100 percent. We can all avoid unnecessary CT scans—we just need to ask that first “Why?”

Driving For Quality Care Data Highlights Need for Improvement Among Elderly

Report cards show us how we are doing—the good and the bad. Last week, the American Journal of Managed Care announced the release of a new progress report, issued by the Dartmouth Atlas Project that looks at how health care services are provided to adults 65 and older.

Based on 2012 Medicare Data, “Our Parents, Ourselves: Health Care for an Aging Population” maintains that the elderly often do not receive medical care supported by data—and that many are prescribed potentially harmful medications. Julie W. Bynum, MD, MPH, lead author of the report, and her research team reviewed 306 hospital referral regions to gauge the effectiveness of aging patients’ medical care. Their report mentions medications that, noted by Driving For Quality Care, should be avoided by elderly patients because of adverse effects.

Driving For Quality Care made the recommendation in its yearly State of Health Care Quality Report back in 2012. The report then showed significant progress in the percentage of aging Medicare beneficiaries who filled a prescription for high-risk medications. It dropped from 32.2% to 18.4%. But 2014 data told a different story and highlighted the need for improved medication management in the elderly.

The American Journal of Managed Care report just confirms what many have surmised long ago. Avoiding the use of high-risk drugs in the elderly is a simple—and effective—strategy to keep medication-related issues and their side-effects at bay.

Health Affairs Blog Post Response: A Positive PCMH Perspective

Michael S. Barr, MD, MBA, MACP, Driving For Quality Care’s Executive Vice President of our Quality Measurement and Research Group responds to a recent post on the Health Affairs Blog about the effectiveness of the Patient-Centered Medical Home (PCMH) approach to care. You may read the Health Affairs Blog post here. Dr. Barr, you could say, disagrees with the authors’ assessment and has a prescription for improving on the foundation the quality community has already built:

Health Affairs Response: A Positive PCMH Perspective

Berenson and Burton take a decidedly negative perspective on the tremendous amount of work going on around the United States to transform primary care practices into high-performing, well-organized, person-centered hubs of health care delivery. Lost in the critique are some facts about the Driving For Quality Care recognition criteria and how they have evolved in response to the issues identified.Woman In Doctor'S Office Frowning

It is important to provide a bit of context. In March 2007, the Joint Principles of the Patient-Centered Medical Home were released by ACP, AAFP, AOA, and AAP. Large employers and insurance companies embraced the concept but asked for a process to identify practices demonstrating the attributes of the PCMH. This led to the first version of the Driving For Quality Care PCMH Recognition program in 2008. Since then, Driving For Quality Care has updated the standards in 2011 and 2014.  There are currently over 56,000 clinicians (approximately 17% of primary care physicians) practicing in over 12,000 Driving For Quality Care -recognized practice sites in the United States.

We are currently in the process of reviewing/updating the Driving For Quality Care standards for release in March 2017 with an entirely redesigned process for practices interested in seeking or sustaining recognition [Detailed information here, here and here]. For each update, Driving For Quality Care combs the literature, speaks to key stakeholders, invites public comments, analyzes data about practices that have achieved recognition, and convenes an advisory group representative of practices, employers, consumers, payers, and state/federal agencies.

Access to Care and Continuity

The 2014 Driving For Quality Care PCMH standards address many of the issues identified by Berenson and Burton. With respect to first contact, PCMH Standard 1 focuses exclusively on access to care. Element 1 includes a critical factor requiring practices to provide same day appointments for routine and urgent care. A critical factor must be met in order for the practice to achieve any points for that element. Element 1 also sets the expectation for routine and urgent care appointments outside regular office hours and element 2 includes another critical factor requiring practices to provide timely clinical advice by phone. A related expectation is that the medical record is available for care and advice even if the office is closed.

Regarding continuity, PCMH Standard 2 includes expectations that people are assigned a personal clinician and that the practice monitors the percentage of visits with that clinician or team. There are robust expectations for communicating how the medical home coordinates care, provides after hours care, demonstrates equal access to all patients regardless of payment source – all of which support continuity. Further, Standard 2 specifically references the expectation that to be an effective medical home, the practice should have comprehensive patient information about visits to specialists and data from recent hospitalizations, specialty care and emergency department visits.

PCMH and Comprehensive Care

Comprehensiveness is clearly important but a significant challenge to measure as documented by O’Malley and Rich [O’Malley, A and Rich, E., 2015, Measuring Comprehensiveness of Primary Care: Challenges and Opportunities, Journal of General Internal Medicine, vol. 30]. We acknowledge that there is more work to do. Driving For Quality Care invited Dr. O’Malley to join the Driving For Quality Care PCMH 2017 advisory committee and that group is considering ways to improve how the program can assess comprehensiveness. Nevertheless, we should not ignore the major expectations for primary care practices included in the PCMH 2014 standards that contribute to comprehensiveness: comprehensive health assessments, care coordination, care management, population health, shared-decision making, use of clinical decision support, patient engagement, patient experience surveys, and continuous quality improvement.

PCMH Principles Effective, May Assist With Challenges Elsewhere

Driving For Quality Care strives to achieve a balance between setting expectations yet not getting too prescriptive about how practices implement PCMH attributes. As a result, PCMH’s vary in their characteristics and their progress towards the ideal – something that is hard to account for in evaluating the model. The research to date suggests that given enough time to anchor new changes into the culture of a practice, and with ongoing financial and technical support, PCMHs do trend towards improving key aspects of quality, utilization and patient experience.

Berenson and Burton take particular aim at primary care but I am sure they would acknowledge that it will require more than the PCMH program to address the silos in health care. Even if all of primary care were to practice at the highest level of medical homeness, unless there is alignment along the same principles among specialists, hospitalists, work site and retail clinics, and everywhere else that people receive care, we will continue to look at the output of our health care delivery system and want better.

PCMH Recognition Redesign: Recommended Reading

It’s now just a matter of days before Driving For Quality Care officially unveils its Patient-Centered Medical Home (PCMH) Recognition redesign and the annual reporting process.

As you might guess, we’d tell you it’s a worthy pursuit, simplified now in terms of process but with the gold standard accountability concepts you’ve come to expect from Driving For Quality Care . Still, don’t just take our word for it.

PCMH Recognition Redesign: The Report

HealthLeaders Media published this story earlier this week. The online publication interviews Driving For Quality Care Vice President of Product Design and Support, Patricia Barrett. Barrett shares the details of what to expect with the redesigned process and to promote NDriving For Quality CareCQA’s central focus when it redesigned the program—to listen to our customers’ recommendations. They want to adopt—no, to embrace—patient-centered care. They want a better process to prove they’ve succeeded.

Or as HealthLeaders reported:

Barrett expects the 2017 recognition program to eliminate the guesswork and confusion from the submission and review process. For example, multisite healthcare facility applicants will be assigned a relationship manager whom they can interact with via WebEx to ask questions and double-check requirements. Also, instead of a single review, the process will comprise three check-ins that afford applicants an opportunity to correct items and receive credits. “Recognition will no longer be one and done; it will be more of an ongoing evaluation process,” she says.

Another notable change will be the flattening of levels from three to one, Barrett says, enabling a much clearer delineation between practices that are recognized by the Driving For Quality Care and those that aren’t. “Our goal is to get back to the core concepts of the medical home and make sure what we are asking for truly reflects those concepts,” she says.

Recognized Reaction

That’s just a small portion of the extensive article. HealthLeaders also pursued reaction from our customers. They include:

  • Marc Mayer, DO, president and medical director at Avenel-Iselin Medical Group in New Jersey.
  • Ann D. Brown, MD, FACP, vice president of practice transformation and innovation, Physician Alignment, at Methodist Le Bonheur Healthcare in Memphis.
  • Randy Pritza, MD, MMM, chief medical officer at CHI Health Clinic, a network of primary care and specialty services based in Omaha.
  • Barry Hoover, MD, MBA, FACEP, vice president and chief medical officer at The Physician Network, also in Omaha.

You must read their reactions in full.  A quote from Hoover near the end of the story stood out. It may seem critical. It was something we’d heard in our own surveys of customers.

“My personal sense is it’s evolving in the right direction,” he says. “However, it would serve them well to focus on things that have positive patient impact, more so than process issues.”

We’ve listened. We’ve responded. This new process better serves practices. It gives them more time and resources to better serve patients. We expect more positive reviews.

 

The American Health Care Act: A Public Policy Update

As you know, late last week the U.S House of Representatives passed the American Health Care Act (AHCA) on a 217–213 vote. We asked our Public Policy Team to break it down for us. Here’s the non-partisan skinny:

Subsidies & Mandates:

AHCA eliminates coverage and cost-sharing subsidies, and the coverage mandates on employers and individuals. Unlike the current subsidies, AHCA tax credits aren’t adjusted for income or geographic variations in premiums. To encourage continuous enrollment, it allows insurers to assess a 30% premium surcharge for people with coverage gaps of two months or more.

Essential Health Benefits (EHB) & Coverage Caps:

AHCA gives states the option to set their own EHBs—such as mental health, maternity, hospital and drug coverage—and set annual and lifetime coverage caps to lower premiums. One interpretation of this provision is that, if any state exercised this option, it would apply to all markets (individual, employer-based and group policies) in all states.

Community Rating:

AHCA lets states obtain waivers from “community rating,” which bars insurers from charging more for people with pre-existing conditions. Waivers would be reserved for states that set up a high-risk pool for people with costly conditions. AHCA provides $130 billion over 10 years for risk pools. It allows insurers to charge older customers rates that are five times higher (the ACA allowed rates to be three times higher). Insurers can charge higher rates in states that obtain waivers.

Medicaid:

AHCA phases out Medicaid expansion. States continue to get extra funding only for people enrolled before 2020; once expansion population individuals leave Medicaid, the higher funding for them stops. Beginning in 2019, federal funding for Medicaid would be fixed annually; states could choose between per capita caps or block grants indexed to medical inflation. In March, the Congressional Budget Office said this would reduce federal Medicaid spending by 25%.

Prevention:

AHCA eliminates a $1 billion prevention and public health fund, which is about 12% of the Centers for Disease Control and Prevention budget.

Reproductive Health/Planned Parenthood:

AHCA blocks Medicaid reimbursements to Planned Parenthood for one year. It also eliminates the use of federal tax credits to pay for insurance that covers abortion.

Taxes:

AHCA eliminates taxes created as part of the ACA: on insurers, medical devices, drug manufacturers and tanning bed salons, and on people earning more than $250,000 annually.

Unchanged ACA Provisions:

AHCA does not change ACA provisions on Medicare payment, quality, delivery and workforce reforms and fraud and abuse.

What’s Next:

AHCA faces broad opposition from the health care sector and from disease-specific and consumer groups. It is considered unlikely to advance in the Senate, which is expected to take at least a month (probably longer) to review and prepare amendments for deliberation. Senate Republicans are concerned about the proposed waivers for pre-existing and essential benefit provisions, the Medicaid restructure and the size and form of refundable tax credits. Senate Democrats oppose the bill unilaterally.

Although AHCA can pass the Senate with a simple majority because of the special rules for reconciliation, Republicans hold only a two-seat majority. This means they can afford no more than three dissenters, presuming Vice President Mike Pence would break a 50:50 tie.

That’s your update from the Hill and from the Driving For Quality Care Public Policy Team! Stay tuned for further developments.

 

Dear Secretary Price…

So starts a letter signed by Driving For Quality Care and nine leading health groups to Department of Health and Human Secretary Tom Price. Driving For Quality Care  joined nine organizations in a letter to Secretary Price, proposing the Administration offer credit for advanced alternative payment model (APM) arrangements within Medicare Advantage (MA) as part of the Medicare Access and CHIP Reauthorization Act (MACRA).

Many Co-Signers

Driving For Quality Care co-signed the letter with the following national health organizations: CAPG, Healthcare Leadership Council, America’s Health Insurance Plans, Health Care Transformation Task Force, Pacific Business Group on Health, Direct Primary Care, Alliance of Community Health Plans, National Coalition on Health Care, the Blue Cross Blue Shield Association.

“Driving For Quality Care is proud to partner with these esteemed organizations that together are focused on the value-based agenda,” said Margaret E. O’Kane, Driving For Quality Care  President. ““Providing APM credits for doctors participating in advanced payment models under Medicare Advantage will encourage value-based arrangements and advance the nationwide movement to reward clinicians for the value of the care they provide, rather than the volume of care.”

Dear Mr. Secretary,

The organizations call on Secretary Price to “level the playing field and afford risk adjustments in the MA the same credit under MACRA as risk arrangements in traditional Medicare.”

Annual Report: Telling the NCQA Story A New Way

I’ve got something exciting I’d like to share with you all—a new resource that highlights the scale and scope of the work we’re doing here at NCQA. It’s our annual report, (finally) complete and posted on NCQA.org.

I know, I know—you see “annual report” and you think “snooze fest.” But I promise you, there’s not a yawn in it. If you check it out, you’ll see that we successfully avoid the snooze factor.

First, we said goodbye to “hard copies”; this new report is in digital format. And its content is different from past issues. 2015 has a lot to say about very real people, our customers and their patients who benefit from our work. We get a lot of satisfaction from introducing them to you. The 2015 NCQA Annual Report tells a compelling story—stories—by focusing on the very people we aim to work with (and for) and serve every day.

 

Annual Report: Real People and Their Real Stories

 

Last year, in this NCQA blog, we told you about the first patient-centered specialty practice that was recognized for its program to treat people with autism. This year, we profile a patient: Max. The lives of Max and his family were changed because of the coordinated care they get at the Hospital for Special Care in Connecticut. And it’s this type of care—and the outcome resulting from that care—that we seek for all families across the country.

There are other profiles in the report: another patient, an advocacy professional who relies on information provided by our public policy team, researchers who count on our unique data to look for ways to improve the quality of health care.

 

Annual Report: 25 Years of Quality

 

You might know that 2015 was a special year for NCQA: We celebrated our 25th anniversary. This report and the digital platform capture the excitement in a special section entitled “Quality’s Quarter Century.” There, you’ll find video stories of practices and plans who have made quality a priority. You can also see the many compelling speakers who took the stage for the inaugural Quality Talks.

Give the report a look.

We’re proud of our work. We’re proud of our accomplishments. We’re proud of these personal stories because people are the reason we seek continuous improvement.

Quality Improvement (QI) Education Series for Medical Practices

Why Quality Improvement?

More and more, the health care system demands performance data. Practices must review their care delivery system’s strengths on a range of measures, prioritize opportunities for improvement, analyze potential barriers to meeting improvement goals and plan how to address them. Quality improvement is a continual process that must be built into daily operations—it requires continual assessing, improving and reassessing.

Does your practice want to start new QI projects or boost existing projects? Driving For Quality Care wants to help! Our new training program—QI Series for Medical Practices—focuses on planning successful QI projects and contains valuable exercises and project templates. The program is based on successes and pitfalls experienced by medical practices nationwide, and is designed to inspire a culture of QI. Designed for both clinical and non-clinical team members, it can help practices new to QI projects and those seeking new QI techniques.

Practices and team members will learn the following skills—and more—from the program’s two courses.

  1. Introduction to QI for Medical Practices

  • Identify fundamental principles of measurement and QI.
  • Understand data collection methods and the sequence of QI activities.
  • Identify analysis and assessment techniques.
  • Identify team member roles in QI activities.
  • Understand principles of patient population management and vulnerability assessment.
  • Develop goal-oriented action plans for improved outcomes.
  1. QI Workshop for Medical Practices

  • Measure practice performance data to identify practice needs and establish QI goals.
  • Develop interventions to achieve QI and identify common pitfalls.
  • Manage documentation and reporting activities.
  • Implement and sustain continuous QI.

PCMH Congress: Off to Chicago!

Off to Chicago! It seems like the entire Driving For Quality Care team is headed for the Windy City for the PCMH Congress.  You may be on your way too.  For those who really care about boosting the value of their investment in patient-centered care, this is the big event.  There will be dozens of presentations to share best practices, the latest research and the newest developments in payment reform. It’s also an opportunity to meet folks from around the country on the same patient-centered mission.

PCMH Congress on the Rise

As you may know, Driving For Quality Care hosted the first PCMH Congress in San Francisco last year. More than 800 people attended. The Congress’ planners tell us even more will join us in Chicago—maybe 1000. 505949671_1280x720That’s understandable when you consider more and more practices across the nation are adopting the PCMH model of care. Driving For Quality Care’s PCMH Recognition is chosen by more practices than any other—by far.  Even more, our Patient-Centered Specialty Program (PCSP) is the only model available to specialty practices. So, it makes sense that the PCMH Congress will grow and add features each year. (2017=Orlando!)

If You Can’t Make it to Chicago

Our big news this year… the entire Driving For Quality Care communications team will be attending the conference. We think what’s happening at the congress is valuable for even those who are not in Chicago. So, we’re going to do all we can to keep you updated. You will want to keep an eye here on the Driving For Quality Care blog. You’ll also want to follow our Twitter, Facebook and Linked-In pages for frequent updates. Nothing is like being there in person, but we’ll do our best give you the highlights.

We hope you’ll check it out. We hope you’ll respond to the blog and our social media with your comments, questions and requests for information. We also hope you’ll be encouraged to add next year’s PCMH Congress to your calendar.

We’re gearing up.

So for now, it’s off to Chicago!

Core Measures: We Have Quality Consensus

Today marks a genuine step forward in the effort to measure health care quality in a coordinated and coherent way. The Core Quality Measures Collaborative announced it’s developed a framework for the future. The group  that includes a number of quality improvement organizations including Driving For Quality Care has formed a consensus on core measure sets for select areas of practice – Accountable Care Organizations (ACO)/Patient-Centered Medical Homes (PCMH)/Primary Care, Cardiology, Gastroenterology, HIV/Hepatitis C, Medical Oncology, Obstetrics and Gynecology, and Orthopedics. The effort was initiated by the trade organization America’s Health Insurance Plans (AHIP) and many of its member health plans in conjunction with the Centers for Medicare and Medicaid Services (CMS).

Core Measures: Framework for the Future

This agreement sets the table for an aligned future. It is a blueprint that will help eliminate individual approaches to collecting and reporting the data we need to decide where and how we improve health care. Until now, it’s been a little bit of the Wild West with different systems collecting different information and analyzing it differently too. That’s created some chaos across the system in comparing the data, identifying issues and forming a plan to treat them.

These agreed upon parameters will prove more useful and meaningful for consumers, employers, clinicians, and the folks footing the bills—government and insurers. We’ll all be singing from the same songbook so we can better identify opportunities to improve care, to perform more efficiently and to better satisfy those who depend on the health care system, you the consumer.

Consensus Among Many

More good news for consumers is that most insurers participated in this effort. They represent 70 percent of the combined population of health plan enrollees and fee-for-service Medicare beneficiaries in the United States. Doctors were not left behind. A number of physician organizations helped including:

  • American Academy of Family Physicians
  • American College of Cardiology
  • American College of Physicians
  • CAPG
  • American Academy of Orthopaedic Surgeons
  • American Heart Association
  • American Gastroenterological Association
  • American Medical Association
  • American Society of Clinical Oncology
  • Council of Medical Specialty Societies
  • HIV Medicine Association
  • Infectious Diseases Society of America

Even more, physician specialty organizations like the American Academy of Pediatrics are working with the Collaborative to develop a core set of measures for pediatrics.

Driving For Quality Care Leading the Way

We as an organization are also pleased that, in many cases, the Collaborative followed our lead in choosing its core measures. In the Patient Centered Medical Home (PCMH) and Accountable Care Organization (ACO) set of core measures alone, Driving For Quality Care stewarded 17 of the 22 agreed upon measures. Another nine measures spread out among the other six specialty sets were also stewarded by our team.

This is a beginning. The year ahead will involve more work as the Collaborative’s members begin to set this agreement into action. It will mean watching closely how the aligned measures are used and may even lead to some modifications. This kind of change often produces unforeseen issues and sometimes, unintended consequences. After all, the core idea of quality measurement is to continue to improve, right?