WASHINGTON, DC-Contrary to popular belief, CMS is in the business of paying for quality care, not just the volume of care provided. We’ve been doing this for about 10 years now, David Hunt, MD, Medical Officer in the Office of Clinical Standards and Quality of the Centers for Medicare and Medicaid Services (CMS)-and a practicing surgeon -said in a miniseminar at the recent annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery.
CMS is no longer the big bad wolf of payment denial; it is now based on the principle that health care dollars are well spent if quality is high. Outcome measures are important, of course, but they are not the true picture of quality, said Dr. Hunt. He did not define what that picture actually is-perhaps because there are no such specific standards-but he did say that evidence-based practice grounded in randomized clinical trials and cohort or ecological studies is the agency’s goal.
Otolaryngology patients (as well as their physicians) are getting older, which is why Medicare plays such an important role in their lives. One of the programs, the Medicare Quality Monitoring System (MQMS), is part of the effort to monitor and improve the quality of care delivered to Medicare beneficiaries.
The features of MQMS include quality indicators of health care, utilization and outcome quality measures, administrative data, trends in the provision of health care, various clinical and topical areas, national and state-level outcomes (not hospital outcomes), and adjustments to standardized distribution based on age and sex.
MQMS also looks at beneficiary characteristics, and utilization describes their demographic distribution and rates of hospitalization for the most common diagnoses and procedures (many of which are otolaryngologic). Data are collected and tabulated for each diagnosis and procedure at the national level and by gender, age, race/ethnicity, Medicaid enrollment status, urban/rural location, and census region.
The Physician Quality Reporting Initiative (PQRI), another fairly recent program, was wildly unpopular when it was first instituted, authorized by the Tax Relief and Health Care Act of 2006.
PQRI establishes a financial incentive for eligible professionals to participate in a voluntary reporting program. Those who successfully report a designated set of quality measures on claims (which involves a mountain of paperwork) can earn a bonus payment, subject to a cap, of 1.5% of total allowed charges for covered Medicare physician fee schedule services.
One of the things that bothered physicians was that CMS posted a letter on its Web site to Medicare beneficiaries with information about PQRI, explaining what the program is and what the implications are for patients. Physicians can choose to provide a copy to their patients in support of their participation in PQRI, but they are not obligated to do so. Neither are they obligated to participate in PQRI, which is not as roundly hated as it used to be.
The VA Model
-David Eibling, MD
David Eibling, MD, Professor in the Department of Otolaryngology Head and Neck Surgery at University of Pittsburgh Medical Center, noted that there are few evidence-based quality measures in otolaryngology, but he encouraged the audience to use those that do exist.
He then went on to discuss the successes of the Department of Veterans Affairs health system, which was turned on its ear by the 1994 appointment of Kenneth Kizer, MD, as Undersecretary for Health. The VA now scores better than almost all other national health care institutions because Ken Kizer initiated a significant amount of institutional change, said Dr. Eibling.
Dr. Kizer has left the VA and is now President and CEO of Medsphere Systems Corporation in Aliso Viejo, CA, but he has spoken about his experiences at the VA and how he instituted the changes that vastly improved the quality of care provided in that system-which used to be one of the worst in the country.
Before 1995, the VA health care system was focused on the episodic treatment of illness, largely through hospitals and specialists, said Dr. Eibling. The system was composed of independent, competing medical centers. There was too much interfacility variation in care delivery and outcomes. Staff was demoralized and veterans found care too difficult to access. Management of the VA health care system was centralized and hierarchical with minor decisions being made at the highest level. The administration was beset by reams of rigid policies and procedures, and it was inwardly focused and perhaps not adequately funded.
Dr. Eibling discussed Dr. Kizer’s enumeration of the critical factors he established and used to improve delivery of quality health care in a fiscally responsible way:
- Clarity of vision. Three strategic goals drove the transformation: creation of a seamless continuum of care, consistency of superior quality, and predictability of good value.
- A new organizational model. Veterans Integrated Service Networks are an organized set of treatment facilities, caregivers, and support services that have a collective goal of delivering services to a defined population in a coordinated and collaborative manner that maximizes the health care value of the service.
- Operational restructuring. Changes included universal primary care, care management, standardized benefits, telephone-linked care, and a shift from hospital-based to outpatient care.
- Funding changes. This was accomplished by implementation of a capitation-based resource allocation system in which basic care accounted for 96% of patients and 62% of funds, whereas complex care accounted for 4% of patients and 38% of funds.
- Information management. This strategy included electronic medical records, which eliminated 72% of all forms, the rest of which became automated. Each patient was given a universal access and identification card.
- Performance management. This strategy aligned the new vision and mission of the VA with quantifiable strategic goals, identifying performance indicators for the goals and holding managers accountable for achieving results.
By closing unused beds, reducing bed days, decreasing hospital admissions, increasing ambulatory care visits, and decreasing staffing, 80% of VA users are now more satisfied than they were two years previously. Significant improvements were achieved in all areas of care-outpatient, inpatient, surgical morbidity and mortality, and preventive care.
As Dr. Kizer said, Rapid change is possible in a large politically sensitive, financially stressed, publicly administered health care system if the simultaneous goals are improved quality, better service, and reduced costs.
Gustatory Impairment in Patients Receiving Head and Neck Radiation Therapy
The goal of radiation therapy is to cure; however, preservation of form and function in the head and neck region is also a factor when making treatment decisions, and side effects must be considered. One potential complication of radiation therapy to the head and neck is taste dysfunction, which can manifest itself as hypogeusia (partial loss), ageusia (complete loss), or dysgeusia (taste distortion). Although compromised taste function can have serious consequences for patients’ health, little protection has been afforded to the taste system during radiation therapy. The Triological Society candidate’s thesis presented by Natasha Mirza, MD, and colleagues reports on a study performed to establish the influences of ionizing radiation on both taste function and structure of patients with head and neck cancer.
The researchers studied eight patients who were to receive radiation therapy to the oral cavity; 17 patients receiving radiation for cancer in other areas of the body served as a control group. Testing was conducted for all subjects about two weeks before radiation therapy was begun, two weeks after therapy was completed, and two months and six months after radiation was completed. A well-validated regional taste test of the lingual region was used, using four stimulants: sucrose (sweet), sodium chloride (salty), citric acid (sour), and caffeine (bitter). The primary outcomes were the four test identification scores and the papillae and pore counts.
Analysis of test results for bitter and salty tastes showed a significant group effect, but no significant time effects or interaction. Sour taste analysis indicated borderline significant effects for time and a significant group-by-time interaction. Sweet taste analysis showed no significant effects of time, group, or interaction between the two factors.
Papillae and pore counts were plotted over time and by group. Significant decreases were observed from pretreatment to the first post-treatment assessment for pore count. For papillae count, there was a significant group effect but no significant time effects or interactions, and for pore count, there were significant effects for both group and group-by-time interaction.
The researchers conclude that the taste function of the head and neck cancer patients was more severely compromised than that of the control group, when there was a compromise at all. In this study, bitter, salty, and sweet tastes were not significantly impaired following radiation therapy; however, sour taste was affected significantly relative to the control group at the first postradiation test. The study also indicated a loss of lingual papillae after exposure to radiation, but by six months postradiation, papillae counts had recovered to the same level as those of the control group.
©2008 The Triological Society