Medicare's Quality Roadmap

Psychiatric Times

October 2005

Vol. XXII

Issue 12

As the national debate over health care continues, the Centers for Medicare & Medicaid Services (CMS) is quietly working on a number of health information technology (HIT) and quality care initiatives that, for better or worse, may help set the course for the way that U.S. health care is provided for the next few years. Most of these initiatives are required by the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (Pub. L. 108-173). There is no certainty that they will improve the delivery of medical care or lower its cost. Yet, since CMS is responsible for the health care of so many millions of Americans the initiatives cannot fail to have a significant impact on the way that physicians, including psychiatrists, practice in the future.

The core of the CMS plan is presented in a July document called the "Quality Improvement Roadmap" that can be found on the Center's Web site <www.cms.gov>. That document, and several pilot programs that CMS has proposed or is now running in test sites around the country, represents an amalgam of current U.S. quality health care concepts and techniques-the so-called "best practices" of clinical care. Why did CMS develop these initiatives and what effect might they have on general medical and psychiatric practice over the next few years?

The main stimulus for CMS' new quality initiatives is a series of reports from the Institute of Medicine (IOM) documenting significant problems in the quality of health care in the United States. The most famous of these reports, "To Err Is Human," estimated that as many as 98,000 Americans die each year, and many additional thousands are injured, as a result of medical errors (IOM, 2000). In a second report, "Crossing the Quality Chasm: A New Health System for the 21st Century," the Institute presented a comprehensive plan for improving the quality of U.S. health care (IOM, 2001). The plan identified six aims for medical care— that it be safe, effective, efficient, patient-centered, timely and equitable. It recommended, among other things, that the U.S. Department of Health and Human Services develop processes to monitor and track progress in the implementation of these six aims, that attention be focused on a group of priority chronic medical conditions (including dementia, depression and anxiety), that there be a national commitment to building a health care information infrastructure, and that payment be linked to the quality and outcome of care. A third IOM report (2004) followed the previous two.

CMS and Quality Care

The CMS endorsed the IOM's six aims in the "Quality Improvement Roadmap" and developed five broad strategies to implement its other recommendations. The first strategy announced CMS' intention to form partnerships with other government agencies, health care organizations, academic institutions and private companies to fulfill the goals described in the Roadmap. This will not be a purely government run initiative. It will have a broad base in the health care community. A substantial number of the initiatives in the Roadmap are, in fact, borrowed from other organizations. The remaining four strategies— which I will call measuring quality, pay-for-performance, HIT and evidence-based medicine— are more specific than the first strategy and will probably have the most impact on individual and group clinical practice.

Measuring quality focuses on identifying and monitoring important clinical indicators and using these data to improve the quality of care. A clinical indicator is defined as an important, measurable component of medical care. Indicators are traditionally divided into process and outcome. Process indicators are measures of the delivery of care, such as the amount of a specific antidepressant medication prescribed for a patient. Outcome indicators are measures of the consequences of care, such as the change in a patient's depression in response to antidepressant medication.

The basic concept of the clinical indicator has been around, in one form or another, for many years. In the late 1980s the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) identified several groups of specialty indicators and asked hospitals to monitor them and electronically transmit the results of their monitoring to the JCAHO every month. The initiative died due to opposition from professional associations. In the last few years, however, the concept has been revived by a number of groups including the Hospital Quality Alliance, Ambulatory Care Alliance and the National Committee for Quality Assurance (NCQA). As a result, there are many indicators now available that CMS can use to monitor the quality of care. In the past, most indicator monitoring has taken place in hospitals and large health plans. In the Roadmap, however, CMS proposes implementing widespread indicator monitoring in private physician offices.

The Doctors Office Quality Information Technology (DOQ-IT) is a CMS program designed to collect a standard set of indicator data from primary care physicians. The data will be entered into an electronic health record (EHR) installed in the physician's office and periodically transmitted over the Internet to a CMS-contracted quality improvement organization, where it will be analyzed. Thirty-five indicators related to the diagnosis and treatment of coronary artery disease, diabetes mellitus, heart failure, hypertension and preventive care measures will be collected. The project is being piloted by 4,000 physicians in four states. Although there are currently no mental health indicators included in the program, it would not be very difficult to start collecting them. The NCQA's Health Plan Employer Data and Information Set, for example, routinely monitors medication management for patients with a diagnosis of major depressive disorder.

Using the Data

The pay-for-performance and evidence-based medicine strategies describe how CMS will use the data it gathers. Medicare and Medicaid have always used a traditional fee-for-service payment system. This approach often leads to high utilization and costly services. At the same time, it offers little reimbursement for efficient medical record-keeping; patient reminder and education systems; prevention programs; high patient satisfaction scores; disease management programs; and other activities that improve the quality, efficiency and continuity of care for individuals with acute and chronic medical problems. The pay-for-performance strategy proposes to change these methods of reimbursement to a new system in which individual physicians, group practices and large health care organizations who can demonstrate improvements in treatment outcome or other quality care indicators will receive a higher reimbursement for their services. The CMS has already conducted a pilot program with 270 nonprofit hospitals that has shown significant improvements in the quality of care with a pay-for-performance system.

The evidence-based medicine strategy describes CMS' plan to use clinical indicator monitoring information, prescription data from the new Medicare Part D drug benefit, and information about treatments and services provided under Medicare Part A and Part B in large-scale, evidence-based medical studies of the effectiveness of current and new treatments for various illnesses.

Electronic Health Records

Electronic information technology runs as an underlying theme throughout the Roadmap, though it is expressed most directly in the HIT strategy. The main goal of this strategy is to encourage physicians to adopt EHRs and electronic or e-prescribing (CMS, 2005) to decrease errors and improve the efficiency, quality and continuity of patient care. Physicians who wish to participate in the program may select from a number of commercially available EHRs that use CMS-standardized clinical data formats for diagnoses, treatments, laboratory results, medical records and health care transactions. To make the transition to an electronic information system easier and considerably less expensive, CMS recently offered physicians a free EHR based on VistA, the Veterans Health Administration's EHR. The new product will be called the VistA-Office EHR. The contracted quality improvement organizations in each state will help physicians chose and install an EHR system.

Discussion

Medicare's Roadmap is more than just a quality initiative. The CMS is, in effect, slowly building a virtual health care system for Medicare, based on a sophisticated information technology infrastructure. It is a logical next step in the electronic government project that began in medicine with the passage of the Health Insurance Portability and Accountability Act (HIPAA) legislation in 1996. Although the use of EHRs and e-prescribing are not yet required, there will probably be incentives to use them in the future.

It is not surprising that monitoring has begun with the treatment of chronic physical illnesses, such as diabetes and heart disease, since they account for a substantial amount of the money spent by Medicare. Moreover, appropriate treatment of these illnesses can substantially improve their course. There is no reason to believe, however, that psychiatric illnesses will be exempt from monitoring. As CMS begins to analyze the prescription of expensive psychotropic drugs, such as the new antidepressants, atypical antipsychotics and newer antiseizure agents, it is likely to begin monitoring depression, bipolar disorder and other chronic psychiatric illnesses. This monitoring will also increase as psychiatrists develop new, expensive biological diagnostic and treatment techniques.

The CMS quality monitoring is likely to make many practitioners and patients uncomfortable. Will the monitoring data be used to identify physicians who are not practicing according to standards of care, limit the prescription of specific drugs for specific illnesses or limit benefits? At the moment, Medicare is only talking about the positive aspects of monitoring-reimbursing more for better care and using data to improve the quality of care. It assures patients and clinicians that it will follow all of the HIPAA-mandated data privacy and security standards, including de-identifying private health information (HIPAA, 1996). Yet, it makes no sense to monitor care without giving feedback to practitioners about their treatment of individual patients. There is no way to improve care without this feedback.

The clinical standardization outlined in the Roadmap is long overdue. It will allow health care providers to share medical data quickly and easily, thereby decreasing errors, duplicate testing, lost records and administrative costs. The National Provider Identifier (NPI), mandated in the HIPAA legislation (1996), is one component of this system. It will give each provider a unique identification code, making it easier to obtain information about that provider, while preventing mistakes that occur when the provider is confused with others who have the same or a similar name. Without such standardization, the health care system would become more chaotic and expensive.

The attempt to introduce a unique health identifier (UHID) or national patient ID provides an example of what happens when there is no standardization. The HIPAA legislation (1996) originally specified that every citizen receive a UHID number to be used in health care transactions. There was significant resistance to the plan, and it was abandoned. Recently, however, health plans and payers were told to stop using Social Security numbers to identify patients. Each plan, therefore, began generating its own patient identification numbers. As a result, patients who change health plans will have different identifiers for each plan and potentially different medical record identification numbers in different health care facilities. This will make it very difficult to maintain continuity of care. Those who are excessively concerned about confidentiality may consider this an advantage. Most people will probably consider it the opposite.

Although methods that increase the accessibility of clinical information and care (such as the NPI and the unique national patient ID) have the potential for abuse, their benefits often outweigh their disadvantages if confidentiality is adequately protected. The development of large health care databases will require new methods of guaranteeing the security of protected health care information. This is something that Medicare should, and appears to, be as concerned about as improving the quality and lowering the cost of care.

Dr. Fauman is the author of Negotiating Managed Care and Study Guide to DSM-IV-TR, both recently published by American Psychiatric Publishing, Inc. He is adjunct clinical associate professor of psychiatry at the University of Michigan and medical director of Magellan Behavioral of Michigan. Dr. Fauman also writes the "Information & Psychiatry" column for Psychiatric Times.

References

CMS (2005), 42 CFR Part 423; Medicare Program; E-Prescribing and the Prescription Drug Program; Proposed Rule (Federal Record, Vol. 70, No. 23, p6256). Available at: www.cms.hhs.gov/medicarereform/E-Prescribing.pdf. Accessed Sept. 6.

Health Insurance Portability and Accountability Act of 1996 (1996), (Pub. L. 104-191) (HIPAA). Available at: http://aspe.hhs.gov/admnsimp/pl104191.htm. Accessed Sept. 6, 2005.

IOM (2000), To Err Is Human. Washington, D.C.: National Academies Press.

IOM (2001), Crossing the Quality Chasm. Washington, D.C.: National Academies Press.

IOM (2004), 1st Annual Crossing the Quality Chasm Summit: A Focus on Communities. Washington, D.C.: National Academies Press.