Consumer Comments on the Proposal for New Medicare Safety Measures
Comments of Consumers Union Safe Patient Project
and its network of consumer advocates for patient safety
To the Measure Application Partnership
January 28, 2013
Consumers Union’s Safe Patient Project and its network of consumer advocates for patient safety (signed below) offer the following comments regarding the January 2013 Measure Applications Partnership Pre-Rulemaking Report: Public Comment Draft.
Generally, we strongly support the direction of this report on expanding public reporting and payment programs, as well as the reorientation the Medicare program is taking to better inform consumers of health care services and to align payments with performance, especially for health care-acquired infections and other harmful adverse events. If all of these measures are adopted by CMS, this will move the country forward significantly in giving the public a fuller picture of provider performance rather than fragments of that picture and will make our health care system safer. While this report’s purpose is not to identify the problem of poor quality and unsafe care, we want to emphasize the gravity and urgency of addressing medical harm. At least one in four hospital patients is harmed, which amounts to approximately nine million people each year. An estimated 225,000 hospital patients die annually due to medical harm. And, we have no good estimates of the level of harm in other health care settings. This is a preventable problem — public reporting and payment adjustments are appropriate and needed methods to stimulate more and improved prevention at all provider levels.
We support the Committee’s emphasis on outcome measures, rather than process measures, and would like to see this report recommend that HHS make a concerted effort to bring forward measures to fill the gaps identified in the report by providing funding for NQF to research and seek out outcome gap measures currently being used on a small scale and to solicit and assist those measure developers in submitting them for endorsement by NQF. We fully support efforts to expand measures to all health care providers, including all types of hospitals (acute care, specialty care, long-term acute care, small rural, large urban/trauma), ambulatory surgical centers, dialysis centers, long-term care/nursing homes, rehabilitation hospitals and services provided by physicians and other independently practicing providers.
We are heartened that so many measures were considered, appreciate the work done to evaluate which measures should move forward, and are encouraged that so many are recommended. More is better – as we are just seeing the tip of iceberg now. While many may complain about the growing list of measures, we support this growth until the measures, taken together when reported publicly, allow for a comprehensive assessment of health care quality and safety. Further, we support restructuring the Medicare payment system so that strong measures are combined to provide a compelling incentive for health care providers to improve safety and desired outcomes. We are concerned that the term “parsimony”, which can mean being careful with money and resources or unusually and excessively stingy, is included as a criteria for MAP to use in selecting measures and has become a commonly used when considering performance measures. Since this term has numerous meanings, the precise meaning should be articulated so there is no confusion by participants or readers regarding which definition is intended. While we support the careful use of resources, we fear the “stingy” meaning could be applied to this wave of consumer-driven demand for information about the safety and quality of health care.
This report identifies as a key issue for hospital programs “the need to differentiate valuable measure alignment from unnecessary measurement duplication,” and the report accomplishes that differentiation. We believe the gravity and urgency of the problem of medical harm warrants tying significant dollars to performance, especially to safety measures. We agree with those on the MAP who felt that approaching the problem from many directions sends a “strong signal to providers about the need for improvement and to adequately reward improvement.” As consumers, we are not confused by the different payment incentive programs. We can understand the difference between a hospital being penalized through the Medicare hospital acquired condition payment reduction program for harm to specific patients and the hospital value based purchasing program that financially rewards the same hospital for aggregately improving its safety. The confusion comes from presentation. In our opinion (and that of the experts – see Judith H. Hibbard, Jean Stockard and Martin Tusler Hospital Performance Reports: Impact On Quality, Market Share, And Reputation Health Affairs, 24, no.4 (2005):1150-1160) the key to alleviating confusion on the part of the public (and probably the providers) is providing a context and understandable explanations about what the information means. When this is done, reports have much more influence on consumers’ views and behaviors. Too often this data is released without appropriate explanation of how it fits into the overall efforts to improve the safety of care.
“Unintended consequences” are mentioned repeatedly throughout this report, while validation of data is not mentioned once. It is imperative that benign terms like “unintended consequences” are discussed in the context of what they really represent: dishonesty, internal pressure on direct caregivers to overlook serious problems, practice of bad medicine and overall gaming of the system. These behaviors should be monitored and when a specific “consequence” is identified (e.g., inappropriately over prescribing antibiotics to avoid high infection rates), we support implementing balancing measures to monitor the inappropriate behavior. However, we strongly agree with the report that “implementation of high-value measures should not be unduly delayed by the lack of balancing measures.” Evidence obtained by HHS of hospitals that are gaming the system should be completely transparent to the public and those providers should be subject to penalties by HHS, especially when the behavior threatens the safety of patients such as overprescribing of antibiotics, which harms individuals and future populations by diminishing our ability to fight superbugs.
The real answer to this problem is validation of data, which we see as essential to creating a reporting system that the public trusts. Validation of the data should be built into the system; with the kind of data searching tools available today, there are probably multiple ways to identify those providers attempting to game the system. HHS should pursue new ways to do this and stop the whining about unintended consequences, which masks a real problem of dishonesty and manipulation.
We appreciate and support the report’s emphasis on the need to increase measurements for patient-centered care. We believe such measurements should include assessing outcomes from the patient perspective, including dignity and respect they encountered (or not) in the delivery of care. Our sense is that building on the current HCAHPS process is the best way to subjectively assess patient experiences, because of its standardized questions and process in randomly selecting patients to complete the survey. There should also be a built in validation process to ensure that providers are not dishonestly gaming the system or manipulating the patients completing the forms. We have several suggestions for HCAHPS expansion:
- Add several questions to HCAHPS regarding medical harm to assess patient reported outcomes. There is clear evidence that health care providers underreport these events and a counterbalance of the patient perspective is badly needed.
- As soon as possible, test HCAHPS in health care environments other than hospitals so this tool can be used across providers, some of which are competing for patients (e.g., hospitals and surgical centers) and warrant an opportunity for comparison by the public.
We would like to highlight a few specific measures:
- We strongly support tying infection measures to payments in the hospital value based purchasing program and, since the MRSA and c.difficile infection measures are near complete endorsement by NQF, we fully support adding these in the next round of HHS regulations on the HVBP program.
- We want to see more maternity related measures and strongly support the recommendation to include C-section rates in the hospital IQR program.
- We appreciate more attention to measures for physicians and other clinicians, but emphasize that pro-active attempts to identify reliable physician outcome measures should be activated. We recognize that MAP “supported the direction” of many of the outcome measures but are holding off until they are endorsed by NQF. Endorsement of these physician measures should become a priority. We are particularly concerned that not a single maternity outcome measure for physicians was endorsed, and recommend those with a “support direction” recommendation be placed on a fast track for NQF endorsement.
- We strongly support the addition of health care -acquired infection measures for inpatient rehabilitation facilities.
Finally, we find the guiding principles adopted by the hospital workgroup (Appendix I) inappropriately hospital focused without consideration of consumer or public interests. The text of this report appropriately describes how this hospital workgroup used these guiding principles, but the appendix document that specifies the principles indicates that they will “inform future revisions to the MAP Measure Selection Criteria.” We strongly oppose MAP continuing to use them to guide future deliberations. The MAP Coordinating Committee did not vote to endorse these criteria and we object to them being used again without a formal endorsement.
In conclusion, this report represents an incredible step forward in assessing the safety and quality of our health care system. We are encouraged by HHS’ push for more outcome and patient safety measures.
Consumers Union Safe Patient Project
512-477-4431 ext. 115
CT Center for Patient Safety
Mothers Against Medical Errors
Yanling Yu & Rex Johnson
Washington Advocates for Patient Safety
Dee Dee Vallier
Americans Mad and Angry [do you still use this site/name]
Hospital infection survivor
Alliance for Safety Awareness for Patients