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Push ahead on qual­ity and safety ef­forts

Modern Healthcare - - Editorial -

Now re­move bar­ri­ers to clin­i­cal in­te­gra­tion, Umb­den­stock says

The pres­i­dent’s sig­na­ture on com­pre­hen­sive health re­form leg­is­la­tion is a long over­due step that will make a real dif­fer­ence for mil­lions of Amer­i­cans. This his­toric leg­is­la­tion ex­pands cov­er­age to 32 mil­lion peo­ple, en­acts sig­nif­i­cant in­sur­ance re­forms and lays a solid foun­da­tion upon which we can con­tinue to build.

Our chal­lenge is to make sure re­form’s foun­da­tion sup­ports and ad­vances what hos­pi­tals are do­ing across the coun­try to make care safer and more ef­fi­cient, ef­fec­tive and trans­par­ent. That is the other story of health re­form—the of­ten un­told story of how many in the hospi­tal field are car­ry­ing out com­mu­nity-based ini­tia­tives that are im­prov­ing care and low­er­ing costs, based on best prac­tices that can be repli­cated na­tion­wide.

The Amer­i­can Hospi­tal As­so­ci­a­tion’s bell­wether strate­gic ini­tia­tive, Hos­pi­tals in Pur­suit of Ex­cel­lence, en­cour­ages and pro­motes th­ese hospi­tal-led ini­tia­tives. Our pur­pose is to share and dis­trib­ute the very best ideas and prac­tices from within our com­mu­nity to our col­leagues in hos­pi­tals and health sys­tems of ev­ery size and shape, and to the pub­lic so they can see the strides that are be­ing made.

The fo­cus ini­tially is on six ar­eas: health­care-as­so­ci­ated in­fec­tions, pa­tient through­put, med­i­ca­tion man­age­ment, pa­tient safety, health in­for­ma­tion tech­nol­ogy and care co­or­di­na­tion. Th­ese ar­eas can pro­duce sub­stan­tial pa­tient and fi­nan­cial value.

The ini­tia­tive seeks to show how to pro­mote ef­fi­cien­cies, op­ti­mize the use of re­sources and en­hance hos­pi­tals’ abil­ity to de­liver safe, high qual­ity and af­ford­able pa­tient care. Its prin­ci­ples are driv­ing na­tional col­lab­o­ra­tive projects, like the ef­fort to gain broad-scale adop­tion of a proven check­list to elim­i­nate cen­tral line-as­so­ci­ated blood­stream in­fec­tions.

The Michi­gan Health & Hospi­tal As­so­ci­a­tion and Johns Hop­kins Uni­ver­sity launched this ini­tia­tive in 2005 to re­duce the rate of in­fec­tions in more than 100 Michi­gan in­ten­sive-care units. The Agency for Health­care Re­search and Qual­ity last fall awarded nearly $7 mil­lion to the AHA’s Health Re­search & Ed­u­ca­tional Trust to al­low hos­pi­tals in all 50 states to par­tic­i­pate in the project. (For more in­for­ma­tion, see on­the­cusp­stophai.org.)

By us­ing the check­list, Michi­gan hos­pi­tals are sav­ing an es­ti­mated 1,500 to 1,700 lives a year and elim­i­nat­ing an es­ti­mated $200 mil­lion in costs an­nu­ally. Just think what we can do when we mul­ti­ply that suc­cess by 50 states.

Re­al­iz­ing re­form’s true po­ten­tial means build­ing a firmer foun­da­tion for th­ese and other ef­forts to im­prove qual­ity and care co­or­di­na­tion, pro­mote in­no­va­tion and re­duce costs. It means re­mov­ing the reg­u­la­tory bar­ri­ers that stand in the way of clin­i­cal in­te­gra­tion among hos­pi­tals, physi­cians and other care­givers.

The In­sti­tute of Medicine’s sem­i­nal work on qual­ity cre­ated a frame­work that has be­come a mantra: care that is safe, ef­fec­tive, ef­fi­cient, timely, eq­ui­table and pa­tient-cen­tered. Achiev­ing the IOM’s qual­ity goals de­mands that hos­pi­tals and physi­cians work to­gether as never be­fore.

Like so much else in health­care, clin­i­cal in­te­gra­tion should be eas­ier than it is. But le­gal ob­sta­cles re­main. The AHA has fo­cused on five in par­tic­u­lar:

Com­pli­cated an­titrust laws hin­der care­givers’ abil­ity to read­ily un­der­stand how they can work to­gether to im­prove qual­ity and ef­fi­ciency. The AHA has ad­vo­cated that the an­titrust agen­cies—the Jus­tice Depart­ment an­titrust divi­sion and the Fed­eral Trade Com­mis­sion—is­sue user-friendly guid­ance that clearly ex­plains what is­sues must be re­solved to en­sure that clin­i­cal in­te­gra­tion pro­grams com­ply with an­titrust law.

The Ethics in Pa­tient Re­fer­rals Act, bet­ter known as the Stark law, has drifted from its orig­i­nal in­tent of pre­vent­ing physi­cians from re­fer­ring their pa­tients to a med­i­cal fa­cil­ity in which they have an own­er­ship in­ter­est. The law re­quires that com­pen­sa­tion for providers be fixed in ad­vance and paid only for hours worked. As a re­sult, pay­ments that are tied to achieve­ment in qual­ity and ef­fi­ciency—in­stead of hours worked—do not meet the law’s strict stan­dards.

The Civil Mon­e­tary Penalty Act also has drifted from its orig­i­nal pur­pose of pro­hibit­ing hos­pi­tals from re­ward­ing physi­cians for re­duc­ing or with­hold­ing ser­vices to pa­tients. To­day’s in­ter­pre­ta­tion pro­hibits any in­cen­tive that de­creases the amount of care a physi­cian de­liv­ers, even if it’s the re­sult of ev­i­dence-based qual­ity guide­lines.

Anti-kick­back laws orig­i­nally sought to pro­tect pa­tients and fed­eral health pro­grams from fraud and abuse by mak­ing it a felony to know­ingly and will­ingly pay any­thing of value to in­flu­ence the re­fer­ral of fed­eral health pro­gram busi­ness. To­day, the law has been stretched to cover any fi­nan­cial re­la­tion­ship be­tween hos­pi­tals and physi­cians, which clearly puts a chill on clin­i­cal in­te­gra­tion.

In­ter­nal Rev­enue Ser­vice rules pre­vent a tax-ex­empt in­sti­tu­tion’s as­sets from be­ing used to ben­e­fit any pri­vate in­di­vid­ual, in­clud­ing physi­cians. The dif­fi­culty arises be­cause not ev­ery pay­ment from a tax-ex­empt hospi­tal to a tax-pay­ing doc­tor vi­o­lates the tax code and IRS rules. But un­til the IRS is­sues guid­ance on the sub­ject, tax-ex­empt hos­pi­tals have no as­sur­ance of how the IRS will rule in a par­tic­u­lar sit­u­a­tion, in­clud­ing on pay­ments as part of a clin­i­cal in­te­gra­tion pro­gram. That un­cer­tainty can be a sig­nif­i­cant de­ter­rent to clin­i­cal in­te­gra­tion.

By bring­ing the health­care rules and reg­u­la­tions gov­ern­ing clin­i­cal in­te­gra­tion into the 21st cen­tury, Congress and the ad­min­is­tra­tion can build on health re­form’s foun­da­tion and sup­port im­prove­ments al­ready un­der way across Amer­ica’s hos­pi­tals that are re­duc­ing costs and en­hanc­ing the qual­ity of care.

Richard Umb­den­stock is pres­i­dent and CEO of the Amer­i­can Hospi­tal As­so­ci­a­tion.

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