Code Blue Resuscitating the External Peer Review Process to Improve Quality of Care and Decrease Hospital Risk

Transcription

1 Code Blue Resuscitating the External Peer Review Process to Improve Quality of Care and Decrease Hospital Risk Gregory Cohen, MD, MPH, FACC Physician Compliance Network, Founder & CEO October 11, 2009

2 Objectives Outline the current state of peer review in hospitals. Discuss how using external peer review can improve hospital/physician relations and physician/physician relations. Original methods of using the peer review process to improve care and decrease the liability of the hospital from lawsuits and government investigations. Background Healthcare spending accounts for 17% of the GDP of the United States There are 46 million uninsured people in the United States. Cardiovascular disease accounts for 43% of Medicare costs. The current rate of growth is unsustainable.

3 Healthcare Reform-Goals Improved access Universal coverage Improved quality Cost control/ cost reduction Increase vertical integration of care through partnerships of physician networks and hospitals Peer Review- Definitions Peer A peer is an individual practicing in the same profession and who has expertise in the subject matter under evaluation. Peer Review Evaluation of an individual physician s professional performance by other physicians which should also include opportunities to improve care.

4 Peer Review Primary means of insuring high quality of patient care Designed to identify errors and opportunities for improvement. Intended to detect incompetent or unprofessional physicians and recommend appropriate corrective action. Means of credentialing and recredentialing physicians for appointment to hospital staff. Peer Review Consistent Peer Review Improve patient care Performance feedback will modify physician behavior Feedback can be based on: 1. Review of specific cases 2. Compliance with surrogate markers of outcomes 3. Actual patient outcomes

5 Peer Review Principle methods to find cases to review. Complaints by healthcare professionals or patients. Review of patients with medical or surgical complications. Review of charts of physicians with high rates of complications or outcomes that deviate from benchmarks Random chart audits. Reasons Physicians Discouraged from Performing Effective Internal Peer Review Reviewers lose time from their practice without compensation. Reviewers may lose referrals from their colleagues they review negatively. Reviewers may be accused of having ulterior motives such as getting rid of a competitor. Reviewers believe they face the possibility of potential lawsuits. If the physician reviewed is a major source of revenue for the hospital, a reviewer may lose favor with administration.

6 Peer Review Internal vs. External If we re going to conduct peer review, an outside body should do it. L. Peeno M.D. Physician Perception of Peer Review Ineffective Punitive Waste of physician time.

7 Peer Review-Regulatory Bodies California Department of Public Health (States) Requires all hospitals to have organized medical staffs. Requires all hospitals to have a have a formal peer review procedures in place. Requires more stringent peer review requirements for hospitals engaging in specializations such as heart surgery Peer Review-Regulatory Bodies Federal Requirements Health Care Quality Improvement Act (HCQIA). Established Standards for hospital peer review committees. Provides immunity for those who participate in peer review. Established the National Practitioner Data Bank (NPBD)

8 Peer Review-Regulatory Bodies Joint Commission-2007 Changes Focused Evaluations New medical staff applicants Current practitioners who request new privileges No evidence of a practitioners competence Negative or failing performances Ongoing Professional Practice Evaluations Continuous outcome and performance data Can come from multiple sources-data bases, resource usage, patient complaints, peer review data When Peer Review Fails

9 Tenet Hospital, Redding CA Between 1995 and 2002, the two physicians performed unnecessary cardiac procedures on more than 600 patients. The two doctors effectively blocked peer review of the cardiology and cardiothoracic surgery. Tenet settled with the victims to pay $395 million dollars. Tenet paid $54 million in state and federal fines. Threatened to be excluded from CMS reimbursement and forced to sell the hospital. Loss of public trust. Peer Review at Redding Medical Center Congressional Report- June 1, 2008 Hospital administrative support of the medical staff to conduct peer review, Alignment of incentives whereas peer reviewers are positively reinforced. Qualified medical staff member participation. Diligent performance of peer review. Proper funding and compensation of reviewers outside of the control of the hospital Methods to protect against retaliation.

10 Peer Review at Redding Medical Center Congressional Report- June 1, 2008 Provide a culture and process that encourages reporting of adverse events including anonymous reporting. Effective oversight by medical staff committees, medical directors, medical executive committee, board of directors, and government agencies. Provide to physicians comparable patient outcomes data. Provide performance feedback and recommendations to treating physicians. Fund random audits of medical images for accuracy, particularly those read by treating physicians. Ineffective Peer Review A Widespread Problem? Mercy Hospital Sacramento 1974 more than 50 unnecessary surgeries Our Lady of Lourdes Regional Medical Center, Louisiana Cardiologist convicted more than 305 unnecessary PCI s. Regional Medical Centro Bayonet Point, Pasco, Florida Hospital suspended 9 cardiologists for failure to follow protocols. Edgewater Medical Center, Chicago, 2001 Cardiologist admitted performing over 750 unnecessary angiograms and angioplasties

11 Ineffective Peer Review A Widespread Problem? Western Medical Center, March 2005 Sued for malpractice 39 times for negligent care University of Kansas Medical Center 33 counts of healthcare fraud by performing unnecessary surgery Garland Community Hospital, 1999 Orthopedic surgeon New Hanover Regional Medical Center,2002 Performed short cut bariatric surgeries, had known history of drug abuse. United Memorial Hospital in Michigan, 1998 Physician convicted of 32 counts of fraud for performing unnecessary pain management procedures by DOJ. Lumetra Study In 2005, the CA Assembly passed legislation requiring the California Medical Board to contract with an independent entity to to conduct a study of the existing state of the peer review process in the state. The study surveyed peer review bodies including hospitals, healthcare plans, professional societies and medical groups. These entities were reluctant to provide information with (70%) not submitting the information requested. Extreme concern with studies design.

12 Lumetra Study-Findings Variation and inconsistency in entity peer review policies and standards. Poor tracking of peer review events Confusion on reporting (805 & 809) Lack of coordination among state agencies, and licensing agencies Burdensome cost of peer review Lumetra Study-Recommendations Redesign the peer review process and create an independent review organization. Improve transparency of the entire review process. Revise the due process hearings Clarify and improve specific provisions of the existing law. Identify funding sources. Start pilot projects to improve the process Report Criticized by the CMA and CHA

13 CCH Healthcare Compliance Letter Monitoring medical necessity in hospitals: A compliance imperative and new challenge in hospital-medical staff relations. - Timothy P. Blanchard, JD, MHA, FHFMA July 26, 2004 Legal Conclusions Whistleblower patterns may proliferate Best defense to such challenges is the implementation of compliance programs procedures tailored to address and avoid allegations of medically unnecessary care in the first place - CCH Healthcare Compliance Letter July 26, 2004

14 Legal Conclusions If cases are ultimately found unnecessary, the ultimate question for the purpose of Medicare overpayment recovery and False Claims Act liability will be whether the hospital knew or should have known that the services were medically necessary - CCH Healthcare Compliance Letter July 26, 2004 Integrity Quality Assurance

15 Physician Compliance Network Founded in 2003 by Practicing Cardiologists with the Goals of Using the External Peer Review Process to: Perform an unbiased evaluation for the appropriateness of invasive cardiology procedures. Improve compliance with recognized ACC/AHA guidelines Decreasing the liability of the hospital from allegations of performing unnecessary procedures. Restore public trust in the medical system Decrease the cost associated with medically unnecessary procedures. Update on Cardiovascular Disease in the United States CV disease is leading cause a morbidity and mortality in the U.S accounting for 36% of all deaths. Total cost of CV disease is $475 billion dollars per year. CV disease accounts for 43% of Medicare costs. In 2002, there were 3 million angiograms and over one million PCI s performed.

16 Reasons for Hospital/Physician Cooperation Increasing Government Scrutiny Use of Recovery Audit Contractors (RAC s) to recover payments. Denial of payments for readmissions. Denial of payments for certain adverse events (e.i., pressure sores, deep vein thrombosis, hospital acquired infections.) Future Integration of Structural and Financial Relationships. Use of False Claims Act to recover funds. Why Should We Perform External Peer Review for Invasive Cardiology Procedures? Increasing utilization of invasive cardiac procedures. Increased scrutiny of cardiac procedures from payers and government. Enforce published guidelines indicating the need for a specific procedure Reduce hospital liability from cases of inappropriate procedures Restore public trust in our own institution and healthcare system.

17 Ethics Survey in Modern Healthcare 2004 Over 70% of healthcare executives surveyed believed that physicians performed inappropriate procedures for monetary benefit. Top Recommendations from the Institute of Medicine Develop infrastructure through public and private sector partnerships Ongoing analysis and synthesis of the medical evidence Delineation of specific practice guidelines Enhance dissemination efforts to communicate evidence and guidelines to the general public and professional committees Development of decision support tools to assist clinicians and patients in applying the evidence

18 Institute of Medicine Report 2000 Patients should receive care based on the best available scientific knowledge. Care should not vary illogically from clinician to clinician or from place to place. Quality Organizations / Report Cards Leapfrog Group Hospital Quality Initiative ACC Registry STS registry

19 Quality Improvement Collection and monitoring of outcomes data. Transparency through reporting and competition. Dissemination of Best Practices. Adherence to evidence based medicine. Peer review is underutilized as a means to improve quality. Inappropriate Care Underutilization Overutilization Misutilization

20 Appropriateness of Care Patient Disease Appropriateness Procedure Quality Outcome Guidelines Not measured at this time Mortality Morbidity Patient Satisfaction Frequently measured ACC/AHA Guidelines Class I Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective Class II Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment Class IIa - Weight of the evidence/opinion is in favor of usefulness/efficacy Class IIb - Usefulness/efficacy is less well established by evidence/opinion Class III Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective and in some cases may be harmful

21 ACC/AHA Classification Class I 64% Class IIA 21% Class IIB 7% Class III 8% Circulation-2005 ACC NCDR 412,617 patients Class I Class IIA Class IIB Class III Evidence Based Guidelines Percutaneous Coronary Interventions Balloon angioplasty, coronary stents Cardiothoracic Surgery CABG, valve surgery Electrophysiology Pacemakers, defibrillators, ablations Peripheral vascular interventions Carotid stenting, peripheral vascular angioplasty and stents

22 JAMA Study 43% of Medicare patients with stable angina did not receive a stress test before and angiogram as recommended by guidelines Variability of Interpretation of Angiograms Evidence of numerous studies show observer variability of 15 % - 45%

23 You make the Call Intermediate Stenoses Severe Stenosis PCN-External Peer Review A Proactive Approach to Peer Review Benefits Eliminates internal bias Allows for standardization of the evaluation process Allows for standardization across geographic regions Increases use of evidence based guidelines Hawthorne effect- improves overall clinical performance Reduce the number of inappropriate procedures thus decreasing costs

24 PCN-Appropriateness of Cardiovascular Care Program Provides an ongoing and continuous peer review process Process is efficient, reliable, and cost-effective. Reviewers are all academically based, board certified and actively practicing if the specialty they are reviewing If a case is found to be inappropriate, a second reviewer will assess the case PCN-Appropriateness of Cardiovascular Care Program The hospital provides a list of all procedures done over a 6 month interval to PCN. PCN randomly selects the procedures to review. The hospital collects and provides the data to PCN. The cases are rated by PCN approved reviewers according to ACC/AHA guidelines. A full report is prepared by PCN and then given to the Medical Executive Committee.

25 Reasons to Address the Issue of Appropriateness of Care Restore public trust in our medical system Improve the quality of patient care Decrease the cost and optimize utilization of the limited resources available Protect physicians and hospitals against criminal and civil penalties Provide more uniformity of care as recommended by the IOM Hospital sends list of all cases for last 6 months PCN randomizes cases PCN sends selected cases back to hospital Hospital quality rep completes data sheets Reviewer gives each case an ACC/AHA score PCN assigns Reviewer Hospital sends cases to PCN Hospital copies angiograms for PCN PCN Supervisor MD reviews inappropriate cases PCN prepares Final Report Final Report delivered to Hospital

26 PCN-Appropriateness of Cardiovascular Care Program Reviews are conducted every 6 months. The cardiologist is assigned an ID number, known only by the Medical Director at the hospital. Approximately 10% of the cases performed are reviewed. If less than 5 cases are performed, all are reviewed. Reviews are contracted through the Medical Executive Committee so the findings can remain privileged. PCN-Appropriateness of Cardiovascular Care Program PCN provides high quality, external peer review in an anonymous, unbiased program, which creates a better working environment for physicians, while improving the quality of care for patients.

27 ACC/AHA CLASSIFICATION Hospital 1 MD I I / IIA IIA IIB IIB / III III TOTALS Hospital I I/IIA IIA IIB IIB/III III TOTALS

28 Hospital 5 MD I I / IIA IIA IIB IIB / III III TOTALS Hospital I I/IIA IIA IIB IIB/III III TOTALS

29 Who benefits from a compliance program for the appropriateness of care? Patients Physicians Hospitals Insurance providers Government payers Hospital Benefits of PCN Appropriateness of Invasive Cardiovascular Care Program All physicians are reviewed in a fair standardized manner eliminating claims of economic targeting or sham reviews. Provides payers with evidence that an effective peer review process is in place. Provides evidence to government agencies that a baseline level of due diligence is being performed to ensure that the invasive cardiology procedures are medically necessary. Provides an extra level of reassurance to patients and the public that only medically necessary care is being provided.

30 Physician Benefits of PCN Appropriateness of Invasive Cardiovascular Care Program All physicians are reviewed in a fair standardized manner eliminating claims of economic targeting or sham reviews. Allows physicians to focus on their own practices. Removes areas of potential conflict with other physicians leading to a more congenial work environment. Provides an outside expert medical opinion that might not be obtained from the current medical staff leading to better care. Provides additional information often more qualitative in nature than the vast number of statistics already provided. Reasons Hospitals Avoid Proactive Review Process Believe physicians (customers) will react negatively or feel threatened by the review process. Believe physicians will move their practices to other competing hospitals. Uncertain regarding the consequences of the findings if one or more of the physicians is found to perform unnecessary procedures. Uncertain on how to address these situations both with the physician and payers. No regulatory body is mandating such a protocol Worry about the cost of the review?

31 Reasons Physicians Avoid Proactive Review Process Physicians don t understand the process. Physicians fear a loss of autonomy. Physicians believe that they are doing everything correctly so that this process provides little or no value. Using an External Peer Review Compliance Program to Monitor the Appropriateness of Invasive Cardiovascular procedures. Questions or Comments?