One of the major questions facing medical practice today is how we measure the quality of care we deliver to our patients.
It is not an easy task.
Most doctors’ offices don’t have electronic medical records, so gathering data by hand is a major barrier. Even those offices with computers don’t have systems in place that can easily gather information (other than for billing purposes), much less analyze it. And, looking at information as part of an overall quality improvement effort is not part of the doctor’s training or routine practice.
Some organizations have made substantial efforts to examine these issues, along with their group practice and individual physician performance. Large medical groups such as Kaiser Permanente have been looking at their practice information and practice quality for some time. There are certainly many others throughout the country who do the same thing. But most doctors don’t practice in such groups, and collecting and analyzing data in a meaningful way is a difficult task for the reasons noted above.
For those reasons, a program that Medicare is undertaking on January 1st is worthy of note. It will be interesting to see how it fares.
Last year, in response to decreasing reimbursements to oncologists for cancer chemotherapy administration in their offices, Medicare implemented what they called a demonstration project. In this project, if the doctor (or the staff) asked the patients receiving chemotherapy a couple of questions regarding pain, nausea and fatigue, the doctor received $130.
The intent of the program was to improve the quality of care for the patients and focus attention on the symptoms cancer patients experienced while receiving chemotherapy. However, it remains unclear what happened to the data from that program and whether or not it had the desired effect of improving the quality of care. After all, aren’t these questions the doctor should already be paying attention to as part of her/his normal care for the patient? And shouldn’t those symptoms be addressed as part of that care?
One of the questions that continues to confront cancer medicine is whether or not patients are getting appropriate treatment at all stages of their disease. What constitutes appropriate treatment may differ in the eyes of one doctor vs. another, but there are some organizations out there that have done an excellent job of establishing reasonable guidelines for cancer care based on the consensus of experts in the field.
So, as opposed to asking questions about something doctors should already be doing, could Medicare do something to address the more general quality of care issues?
In response, this coming year on January 1 Medicare will modify their original program described above, and institute another one that is more focused on the actual overall quality of care provided the patient.
What Medicare has done is establish a program where the oncologist who sees a cancer patient for an office visit can submit a code to Medicare through the billing system, and be reimbursed $23 extra every time they see the patient who has one of 13 cancer diagnoses which are part of this program (see the press release from CMS for more specific details of the program and the diseases being covered).
The doctor’s report has to include the code describing the primary focus of the office visit, the patient’s current disease state, and whether the patient’s care adheres to clinical guidelines as provided by that National Comprehensive Cancer Network (NCCN) or the American Society of Clinical Oncology (ASCO). The doctor can also indicate that the guidelines were not followed, because of patient preferences or because the doctor didn’t agree with the guideline.
One of the specific questions on the list is whether the patient’s care is affected by participation in a clinical trial. Since the doctors are being encouraged to adhere to clinical guidelines, it may not be such a long step to start enrolling patients in clinical trials. Increased participation in clinical trials is important if we are to continue to quickly improve the treatment of cancer in this country and the world.
Medicare says in its press release, “This demonstration also meets the objective of helping us learn to what extent Medicare beneficiaries are being treated in a manner that yields the best outcomes, understand clinical cancer scenarios where there is not a clinical consensus among physicians on the relevance of specific guidelines, and ensure that due emphasis is placed on a multi-disciplinary, comprehensive approach to palliation and end of life care.”
That’s a pretty tall order, but if it works it will represent a major step forward in patient care, especially if the data really help meet the objectives noted above. It is particularly important since cancer for the majority of folks is a disease of aging, so much of the treatment for cancer in this country is paid for by Medicare.
I should note that Medicare is not the only health organization that is looking into ways to improve the quality of care patients receive. There are many initiatives underway in the private sector as well, including efforts by accrediting organizations such as NCQA and JCAHO, insurance companies, and medical associations.
One collaboration in particular, the Ambulatory Care Quality Alliance, has brought together representatives of all of these groups—including the federal government agencies with an interest in this issue—to develop common measures that can be used by all of the organizations to examine the quality of medical care.
Another organization, the National Quality Forum, has a several year history of collaboration to arrive at valid measures of quality that can be used in the same manner.
We are going to see more and more of these types of activities which promote quality medical care. Consumers, insurers, the government—and, yes, medical professional organizations such as the American Medical Association—all realize that we have to do a much better job of documenting the quality and effectiveness of the care we provide. There is a huge demand from many sectors that we demonstrate that we are in reality providing the highest quality of medical care in the world to our patients. It is no longer sufficient to say we are doing it—we have to prove we are doing it.
There is nothing wrong with the concept, but it is the approach as to how we get this done that is going to be difficult.
If the Medicare project demonstrates real results showing that this method can improve the quality of patient care without being excessively intrusive or costly, then it could be the first real step down a road that has a long way to go.