The CMS announcement that it will no longer reimburse hospitals for treating eight preventable conditions beginning a year from now signals two important payer trends that hospitals would be wise to note. First, the momentum toward accountability and transparency continues at a rapid pace; and second, purchasers are less passive in their demands for high-quality care in a safe environment.
The new CMS measures will certainly result in better care and better patient outcomes, and the focus on quality and patient safety is a positive step to ensuring the American healthcare system is the best it can be. This isn’t to say that hospitals haven’t been working on improving care—they have. For years, hospitals have been making tremendous strides in attacking issues like ventilator-associated pneumonia, surgical infections and other complications as well as improving care and decreasing costs.
Unfortunately, the CMS may have made assumptions that play out differently in reality than in theory. While perhaps reasonable, the CMS’ assumptions regarding hospitals’ and clinicians’ ability to make changes may also be potentially erroneous.
In reading the final rule, the CMS indicated that it reached its decisions based upon review of medical literature and in consultation with experts such as the Centers for Disease Control and Prevention. These steps seem perfectly reasonable and the final rule is excellent where it provides detailed information regarding the evidentiary literature to support the decisions. So, what’s the problem?
The problem is that knowing the scientific literature is only one aspect of the issue of quality and patient safety. The other information that needs to be considered is how hospitals can take steps to implement performance improvement. Without an implementation plan, hospitals and physicians are left without a road map that clearly defines next steps. Are there best practices or approaches to helping hospitals implement such changes or should hospitals and physicians be left to solve these implementation matters on their own?
Given the investments the CMS made, it is doubtful it would spend so much time, energy and resources toward improving quality and patient safety only to walk away from the hard work of implementing the changes, unless it assumed that hospitals and providers would know how to efficiently implement the identified measures. The failure to disseminate clear plans of implementation may be costly at best, or worse, may undermine efforts to improve performance.
The Aug. 9 issue of the New England Journal of Medicine highlighted concerns regarding the lack of evidence for certain quality improvement interventions. Given that the CMS has publicly reported performance measures for years, it would stand to reason that every organization would try to meet these challenges if it knew how. Perhaps the reality is that there are hospitals and physicians who are doing their best to meet these demands, but they lack the information needed to effectively and efficiently implement practices to meet requested levels of performance.
The new CMS measures will undeniably energize existing improvement clinical efforts because hospital leaders will not want to forgo reimbursements. This rule also provides hospital leaders with a “mandate” to approach their medical staff in a way that may not have been as warranted prior to now. For example, the CMS has informed hospital leaders that a wrong-site surgery may subject the entire institution to termination of Medicare participation. The seriousness of the approach demands that hospital leaders and medical staff work together—not separately—on matters of patient safety.
The new CMS measures provide an opportunity for growth and improvement. Keeping patients safe is, or should be, the foundation of the healthcare industry. If problems can be prevented, then everyone has a stake in making this happen. The CMS mandate forces hospitals and caregivers to realize that they will be held publicly accountable for their efforts.
Perhaps the CMS would make better strides in the long term if its focus was not only on results, but also on the approach. The CMS should reward hospitals or organizations that disseminate research and information on how to implement best practices in the best manner. It would be well worth the dollars to establish research and financial rewards that lead to the development of “implementation science.” Such an endeavor would remove the biggest barrier from achieving or sustaining performance results, which is that despite great desire, hospitals may simply not know how best to implement practices.
Nevertheless, with the final rule, the CMS has de facto prioritized areas of focus for hospitals that cannot be ignored. The problem is that the CMS has given us a picture of a perfect house, but healthcare providers at the moment have no clear plan on how to build it.
Trent Haywood, M.D., is senior vice president and chief medical officer of VHA and a former CMS deputy chief medical officer.
