Methods to develop arthritis and osteoporosis measures: a view from the National Committee for Quality Assurance (NCQA).

OBJECTIVE: Performance measurement at various levels of the health care system promotes improved processes that can result in the provision of more consistent and effective care. This chapter articulates the methodology and criteria utilized in measures development to ensure accountability and serve the information needs of physicians, health care systems, health plans and consumers, using arthritis and osteoporosis as example conditions. METHODS: Observational studies conducted to assess the validity and feasibility of performance measures focused on arthritis and osteoporosis. Clinical expert panels were convened to develop measure specifications based on guidelines and evidence supporting critical aspects of care. The aspects of care that were assessed included: DMARD utilization for patients with rheumatoid arthritis; appropriate gastrointestinal prophylaxis for patients utilizing NSAIDS; comprehensive osteoarthritis care; comprehensive symptom assessment and medical management of woman over 65 years who experienced a bone fracture. RESULTS: The implementation of performance measures for key aspects of arthritis and osteoporosis care is challenged by the availability of administrative data. However, potential for improvement is evident in each of the areas studied. CONCLUSION: The key challenge to the feasibility of arthritis performance measures is the lack of administrative data to identify the eligible population. Administrative data capture suffers as a result of under-coding and under-recognition of arthritis. Consensus around a single set of measures creates a powerful tool for focusing on key components of care as a basis for quality improvement and allows for a valid comparison of care within and across health care settings.

Effect of education and feedback on thyroid function testing strategies of primary care clinicians.

We examined the effect of an educational memorandum incorporating simple guidelines for thyroid function testing on test utilization in a primary care health maintenance organization practice. We then compared the effectiveness of a reminder alone or combined with individual test ordering feedback at maintaining an effect. The subjects were 17 physicians and 13 physician assistants and nurse practitioners separated into two similar study groups with little clinical interaction. Both groups responded to the education with increased compliance (from 36% to greater than 67%) with the recommended testing strategy. The group subsequently receiving only a reminder showed a further increase in compliance from 68% to 81% at 6 months and 79% at 12 months. The group receiving a reminder and feedback showed no subsequent change in testing pattern (65% compliance before the reminder-feedback and 64% at both subsequent measurements). The effect of the educational intervention was greater on nurse practitioners and physician assistants than physicians (absolute increase in compliance, 63% vs 28%). We conclude that education can be an effective tool for modifying clinician testing patterns to conform to simple clinical guidelines. Further study of the effect of education and other strategies on compliance with more complex guidelines is needed.

The decision to execute a durable power of attorney for health care and preferences regarding the utilization of life-sustaining treatments in nursing home residents.

One hundred three nursing home residents were interviewed regarding their preferences for the choice of an agent for health-care decision making while being offered the opportunity to execute a Durable Power of Attorney for health care. They also completed a questionnaire that tapped their preferences regarding the use of four types of life-support treatment under three hypothetical levels of future cognitive functioning. Factors that might influence these preferences, such as previous experiences with life-sustaining treatments, religious beliefs, and personal values, were also examined. Participants tended to choose their son or daughter as their agent for future health-care decision making. They had clear and consistent patterns of preferences regarding the utilization of life-sustaining treatment. Generally, participants opted not to be treated, although there was variability among participants. They were even less inclined to opt for treatment as their perceived level of future cognitive functioning declined, or when the life-sustaining treatment involved permanent rather than temporary procedures.

Hospital length of stay of frail elderly patients. Primary care by general internists versus geriatricians.

Hospitalized patients in a medical diagnosis-related group (DRG) who were cared for by physicians in a division of Geriatric Medicine (geriatric group) were compared with a control group drawn from a stratified random sample of patients cared for by general internists (internist group) in the same hospital. Despite an older age, longer predicted length of stay, and higher DRG reimbursement, the geriatric group patients had a significantly shorter length of stay (8.8 vs 15.8 days; P less than 0.05) than the internist group. A shorter length of stay for the geriatric group was noted in each of five subgroups, sorted by admission and discharge status. Comparison to national data reveals that, despite the shorter length of stay in the geriatric group, length of stay data used by hospitals for management purposes would still classify the patients of the geriatrics group as "revenue losers" under the Medicare hospital reimbursement system.

Clinical funding for geriatric fellowship programs.

The Medicare program provides the largest single source of funding for the clinical portion of housestaff training programs. Despite the fact that the clinical training in geriatric fellowship programs focuses heavily on the care of Medicare recipients, the proportion of funds supporting geriatric fellowships that is derived from Medicare is actually smaller than that of most other fellowship programs. Legislation passed by Congress in 1986, and just recently implemented, creates an opportunity to increase Medicare funding for geriatrics. Those concerned with geriatric fellowship training must have a clear understanding of how Medicare funding for graduate medical education will occur under the new legislation if the opportunity is to be used effectively. Finally, other barriers created by general pressures on housestaff budgets that may interfere with capitalizing on the opportunity are discussed.

Financing long-term care. The growing dilemma.

The financing of long-term care is one of the largest and most vexing health care problems facing our society. The problem will be further exacerbated when the rate of growth in the number of persons needing long-term care is further accelerated by the graying of those in the "baby boom" generation. The current financing mechanism, which relies almost entirely on concurrent funding through either a means tested welfare program (Medicaid) or self-pay, is inequitable and inadequate even for our present needs. Despite the magnitude of the problem, only recently has sufficient attention been focused on finding alternatives to the current means of financing long-term care. The search for a solution has been hampered by multiple, and sometimes conflicting, policy and political considerations. After reviewing the demographic and social roots of our current dilemma and listing the major alternatives for financing long-term care, a series of basic principles and definitions are reviewed. These elements are meant to serve as guidelines to compare and evaluate the growing number of proposals which seek to create a more effective and equitable system for financing long-term care. Future articles in this section will detail some of the more promising approaches to the dilemma of financing long-term care.

Physician Payment Reform. Implications for geriatrics.

A consensus has developed on the need for a major revision of physician reimbursement in the Medicare program. The Physician Payment Review Commission has recommended to Congress a series of far-reaching changes in the payment system, based on the development of a fee schedule using a Resource Based Relative Value System (RBRVS). This article explores the rationale for the recommendations and the probable impact on Medicare beneficiaries and their physicians if the changes are enacted. Special consideration is given to unique aspects of geriatric medicine, including comprehensive geriatric assessment.

The impact of OBRA on medical practice within nursing facilities.

Major changes in the federal oversight of nursing home care were passed by Congress and became law as the Nursing Home Reform Amendments of the Omnibus Budget Reconciliation Act of 1987 (OBRA 87). The final regulations to implement OBRA 87 were published in September, 1991. The intent of this article is to provide an overview of selected parts of the nursing home reform regulations, which have a direct impact on physician practice within nursing facilities, and to offer strategies for successful management of the changes that are required. A brief review of the origins of the legislation and the process by which law is turned into practice is provided as a context in which to understand the changes mandated by the Nursing Home Reform Amendments of OBRA 87.

The Medicare Prospective Payment System and the care of the frail elderly.

The development of the Medicare Prospective Payment System based on diagnosis-relating groupings is reviewed. Special emphasis is placed on analysis of the provisions that have a potential impact on geriatric medicine and on the care of the frail elderly. The authors conclude that in its present form, the DRG system may systematically undercompensate hospitals for treating the frail elderly and, therefore, result in attempts by some hospitals to reduce or avoid altogether programs in geriatric medicine and admissions of frail elderly persons. These effects, together with federal and state efforts to limit nursing home and home care costs, may result in a major under-provision of care for the frail elderly and exclusion of clinical geriatric medicine from the medical care system.

Wheelchair use by ambulatory nursing home residents.

In a survey of wheelchair use in two nursing homes, the authors found a substantial number of cognitively intact nursing home residents who walked, but who also used a wheelchair. Using chart review and interviews with the residents, it was found that multiple physical factors, including pain, strength, endurance, vision and balance, and multiple social and environmental factors, including the fear of falling, were related to the resident's decision to use a wheelchair as an alternative means of mobility. A physical examination focused on aspects of mobility was completed on each resident and was intended to characterize the physical limitations in groups studied. In the nursing home environment, use of the wheelchair is viewed by the residents as a self-initiated choice which the residents believed significantly enhanced their sense of well-being. Finally, there was minimal recognition of mobility as a problem on the part of the medical and nursing staff. The study raises a number of important issues concerning walking versus wheelchair use in the nursing home.

Financing long-term care. An insurance-based approach.

A joint public-private insurance program is the best approach to resolving the problem of financing long-term care. In this report, we describe one possible approach in detail. A modest expansion of the current (ie, after repeal of the Medicare Catastrophic Coverage Law of 1988) Medicare benefit for persons needing relatively short-term nursing home and home care services would be a first step. For those with extended long-term service needs, a non-means tested, publicly funded program with joint federal-state financing and administration would provide coverage after a substantial elimination period and with an income-related copayment. Private long-term care insurance purchased through employers before retirement or in the periretirement period, through use of income or equity accumulated in life insurance, pension funds, or home ownership, would be used to fund the exclusionary period or copayments of the public program by those who wish to have greater protection for income or assets. The role of Medicaid would be limited to paying for the deductible, copayments, and initial long-stay expenses of those with low incomes and limited assets.

Medical students' attitudes toward the elderly.

A study was designed to examine the relationship between students' attitudes, their willingness to work with elderly patients, and the impact of a geriatric rotation on a randomly selected subset of the group. A pretest/post-test design was used in which 148 third-year medical students completed a multidimensional questionnaire on two occasions eight weeks apart. Highly significant correlations were found between the expressed intention of the student to work with the elderly and positive feelings about previous professional contact (r = .26, P less than .001), previous personal contact (r = .17, P less than .002), belief that working with the elderly is rewarding (r = .30, P less than .0001), high degree of comfort in working with the elderly (r = .21, P less than .01), and positive stereotypes about the elderly (r = .14, P less than .05). Despite the students' positive rating of the geriatric rotation, multiple regression analysis indicated that the best predictor of an index of intentions to work with elderly patients on the post-test was this same index of intentions on the pretest (multiple r = .58, P less than .001). These findings, as well as the actual attitudes and stereotypes held by the students, have major implications for the planning and development of medical students' experiences in geriatrics.

An overview of allocation and rationing: implications for geriatrics.

Geriatricians are faced with increasing pressure from insurers and the public to control costs. At the same time, subspecialist colleagues, patients, and the courts often demand ever more costly high-technology interventions. This conflict will only intensify given the sustained increase in the percentage of GNP spent on medical care. A number of prominent biomedical ethicists and others have explored rationing of medical care services as one response to these concerns. This is the second in a series of articles in the Journal in response to the Oregon Health Decisions Initiative and is designed to provide (1) a brief ethical perspective on rationing and allocation; (2) an analysis of our present, largely implicit, approach to rationing and allocation; and (3) some suggestions that might move the United States closer to a more coherent and reasonable means of allocating and rationing health care.

Medicare reimbursement for geriatric assessment: report of the American Geriatrics Society Ad Hoc Committee on Geriatrics Assessment.

This ad hoc committee report from the American Geriatrics Society proposes the prompt initiation of Medicare reimbursement for geriatric assessment (GA) services (also termed comprehensive geriatric assessment or geriatric evaluation and management services). Despite an extensive body of literature documenting the effectiveness of GA for improving health care outcomes in many settings for identifiable groups of frail elderly patients, no explicit Medicare reimbursement mechanisms currently exist to cover GA services provided by either hospital or physician. We believe that new physician reimbursement codes specific for geriatric assessment should be established in the Current Procedural Technology (CPT-4) manual and that reimbursement for GA should be specifically provided under Part B of Medicare. Further, we believe that hospital reimbursement within the Medicare prospective payment system should be modified to encourage GA during inpatient stays for appropriate patients. This paper summarizes the background for these recommendations. It defines the major content of GA at three levels of intensity--screening, intermediate, and comprehensive. It describes the major sites for conducting GA--hospital, office, home, nursing home. Finally, it proposes criteria for targeting patients most likely to benefit from GA.

The Managed Care Education Clearinghouse.

The authors surveyed all 125 allopathic medical schools to determine the number of schools that had implemented a formal curriculum in managed care and how many had a substantial interest in a Web-based clearinghouse for managed care curricular resources. They describe the results of their survey and the Web site they developed, the Managed Care Education Clearinghouse.

A new measure of the impact of managed care on healthcare markets.

BACKGROUND: Most studies of managed care impact have used health maintenance organization (HMO) penetration or index of competition as the marker of managed care impact. However, little empirical evidence has been found to support the validity of these or other measures in current use. In addition, as managed care evolves to forms other than HMOs and managed care penetration in large metropolitan areas approaches 100% of commercially insured patients, the utility of the most commonly used measure, HMO penetration, will decrease still further. OBJECTIVES: To provide a preliminary analysis of the use of premiums as a measure of market impact of managed care. STUDY DESIGN: Retrospective analysis (quartile, correlation, multiple-variable linear regression) of publicly available datasets. METHODS: Labor market-adjusted HMO premiums from 3 publicly available sources, for the 56 largest metropolitan areas in the United States, were compared with penetration and index of competition as predictors of the dependent market variable, hospital bed-days per 1000 population. RESULTS: Health maintenance organization premiums in the Federal Employees Health Benefits Program emerged as the best predictor of HMO market impact. Average HMO premiums reported in the Interstudy database and for the Medicare+Choice program also outperformed penetration or index of competition in relating to several commonly available markers of competition such as bed-days per 1000. CONCLUSIONS: Premiums charged by HMOs are a useful measure of the impact of managed care on healthcare markets in large metropolitan areas.

The costs of a family practice residency ambulatory care program.

The cost of patient care service and education occurring in a family practice residency unit of a community based prepaid health program was determined from accounting records. The cost of producing the same number of patient visits in comparable family practice units which did not have residents on-site was determined in a similar manner. The cost per visit in the residency unit was $15.53 while that in the nonresidency unit was $13.92. There was an excess cost of $1.61 per visit in the residency, or, based on the number of residents present, a net cost of $7 per resident per day. None of the costs of central residency program administration or of ambulatory based subspecialty rotations were included. While a small increase (ten percent) in productivity or efficiency would result in the residency patient care unit itself being self-sustaining, this study casts considerable doubt on the ability of the model family practice residency unit to offset the full costs of the ambulatory care portion of family practice residency training.

The cost of medical student instruction in the practice setting.

Using an incremental cost approach, the cost of instruction for medical students participating in a variety of ambulatory-care, chiefly family-practice, experiences in several clinical practice sites was examined. The costs ranged from $5 per student per day for a first-year observational experience to $112 per student per day for a second-year preceptorship with direct patient care involvement by the students. Factors such as the previous experience of the student, the baseline productivity of the site, the number of examining rooms, the income source of the preceptor (salary vs fee-for-service), and the clarity of preceptor role definition are discussed in relation to cost. The lack of defined, stable income to offset costs is noted. In view of the substantial costs of instruction in ambulatory family practice clerkships, clearly defined ongoing sources of income must be provided to ensure the continuation or expansion of these vital experiences.