PPACA Care Provisions: Hospital-Acquired Infections

The Patient Protection and Affordable Care Act penalizes hospitals by reducing payments for treatment of hospital-acquired infections and imposes monetary penalties of hospitals with the worst HAI rates. The severity of this problem is covered in my previous posts below. In the US 1.7 million HAIs occur per year, killing 99,000 people. This is more people than are killed yearly by car accidents, breast cancer and AIDS combined. The annual cost of these infections is $35-45 billion.

Hospital-Acquired Infections September 1, 2010
Hospital-Acquired Infections October 6, 2010
Hospital-Acquired Infections July 11, 2011
Hospital Hazards September 1, 2011 (section on HAIs)

PPACA Care Provisions: Quality Measurements

The PPACA required that the results of the National Quality Strategy be measured by ten outcome measurements each for acute and chronic care diseases and for preventive and primary care. Health and Human Services has contracted with the non-profit National Quality Forum for these measurements. There are currently 598 endorsed quality measures on the NQF website.

Taking the first item on the list, asthma assessment, the American Medical Association-Physician Consortium for Performance Improvement (AMA-PCPI) was put in charge of this quality measurement and produced a standard that was adopted in 2009 and is currently undergoing maintenance. The measurement is published by the HHS Agency for Healthcare Research and Quality (AHRQ). For a layperson, a quality asthma assessment consists of at least two office visits in a calendar year by a person 5-40 years of age, at which daytime and night-time asthma symptoms are recorded, quantitative measurements of the person's ability to get air into and out of their lungs are made, asthma attacks are recorded, asthma's effects on the person's quality of life are determined, short-term and long-term drugs are evaluated, along with whether the drugs are actually being bought and used as instructed. Doctor-patient communication  and patient satisfaction are reported by National Asthma Education and Prevention Program/National Heart, Lung, and Blood Institute (NAEPP/NHLBI) guidelines.

PPACA Care Provisions: The National Quality Strategy

Having heard about the individual mandate and other insurance provisions of the Patient Protection and Affordable Care Act ad nauseum, I decided to use the Scribd document below as a basis for expanding on the care provisions of the law.

The PPACA mandates an annual report on the development and implementation of a national strategy to improve health care quality. The report is here and the executive summary is reproduced below.

Executive Summary  

The Affordable Care Act seeks to increase access to high-quality, affordable health care for all Americans. To that end, the law requires the Secretary of the Department of Health and Human Services (HHS) to establish a National Strategy for Quality Improvement in Health Care (the National Quality Strategy) that sets priorities to guide this effort and includes a strategic plan for how to achieve it. This report describes the initial Strategy and plan for implementation.

The National Quality Strategy will promote quality health care in which the needs of patients, families, and communities guide the actions of all those who deliver and pay for care. It will incorporate the evidence-based results of the latest research and scientific advances in clinical medicine, public health, and health care delivery. It will foster a delivery system that works better for clinicians and provider organizations—reducing their administrative burdens and helping them collaborate to improve care. It is guided by principles (available atwww.ahrq.gov/workingforquality) that were developed with input by stakeholders across the health care system, including Federal and State agencies, local communities, provider organizations, clinicians, patients, businesses, employers, and payers. Most importantly, the implementation of this Strategy will lead to a measurable improvement in outcomes of care, and in the overall health of the American people.

An update for 2012 is available here on the Agency for Healthcare Research and Quality website. Within the update, here is the FDA's section of the plan as an example of one of the eight agencies. There is a ninth section for agency leadership.

Priorities

Making care safer by reducing the harm caused in the delivery of care.

Safe Use Initiative. The Safe Use Initiative is an FDA Center for Drug Evaluation and Research nonregulatory program through which collaborative cross-health sector projects are created to better manage specific preventable drug risks and reduce preventable harm from FDA-regulated drugs. Adverse events from drug use are estimated to result in more than 4 million visits to emergency departments, doctors' offices, or other outpatient settings annually. Innovation and improvement of risk management approaches through collaborations between federal agencies and the broader health care community can reduce preventable drug harm through increased communication, engagement, and action across all sectors of public health and health care. The metrics will be based on the specific project's objectives and outcomes. FDA and interested collaborators will develop appropriate evaluation metrics to measure an approach's success.

The overall national goal is an improvement in way things turn out for someone who is receiving health care. This is commonly referred to as the outcome, and will be a topic of later posts. One of my earlier posts, Payments for Services, Payments for Outcomes has already touched on this topic.

Health Care Shalls in the Affordable Care Act

PPACA and The US Supreme Court

Next week will probably bring the Supreme Court decision on the Patient Protection and Affordable Care Act. At the time the court accepted the case, my somewhat informed prediction was that their decision would be 7-2 in favor. Lest you doubt my sanity, there were better informed people who predicted 8-1 in favor. My prediction may yet be vindicated if Chief Justice John Roberts takes the view that a partisan decision against the PPACA would reflect poorly on the court's reputation and his own.


The bulk of the media have reported the decision as if they were covering a horse race and made speculative inferences from the oral arguments. This type of coverage has, IMHO, affected the national polls and brought forth the question of how insulated the court's decision-making process might be from the partisan divide which is the national news topic.


Polls and pundits currently predict that the court will break away from past legal decisions supporting the individual mandate as being within the range of powers granted to the federal government, declaring only that part of the PPACA an unconstitutional extension of government power. If the media and poll majorities have correctly predicted this outcome, what of it? The individual mandate as written in the PPACA is unenforceable.


The comparison between Massachusetts' experience under Governor Romney and states such as my native Texas is made by Paul Starr in The New Republic.

The one state with a mandate hardly offers much guidance. Massachusetts now has near-universal coverage, but, even before its recent reforms, only about 10 percent of its population was uninsured. Romney’s program passed with overwhelming support from both Republicans and Democrats in the state legislature. Business, labor, and the health care industry all backed the law. And, when the mandate went into effect, the agency in charge of the program ran TV ads with stars from the Boston Red Sox saying it was time to get health insurance. In some states today, by contrast, the uninsured represent 20 percent or more of the population, and, instead of elite-led support for the health care legislation, there is elite-led opposition. Under those conditions, open defiance of the mandate will be respectable, and compliance with the mandate may be much lower than the official estimates assume.

Sarah Kliff made the comparison to Washington state's repeal of an insurance mandate in two Washington Post articles. A graphic representation of what happened to insurance companies in Washington state selling individual policies is presented by Aaron Carroll of The Incidental Economist.

Experimentation at the state level is one possible answer to a Supreme Court finding that the individual mandate is an unconstitutional extension of the power of the federal government. Charles Goozner presents options in his post at GoozNews, Why Reform Will Survive Mandate’s Fall.

Happy Mother's Day to Ann Dunham

President Obama's desire to cut administrative costs, save forests from paper mills, and provide better coordinated health care by digitizing medical records makes sense. I wouldn't be surprised if, like the Patient Protection and Affordable Care Act, it arises from his mother's experience of the US health care system and private insurers. The satirical website Extormity was created to mirror the voluntary electronic health record system which preceded the 2009 HITECH act, and I'm sure they still find much material worthy of satirical treatment. 

Incentives, Disincentives, Best Results Thus Far

By law, there are now monetary incentives for innovating and implementing digital health care records. As part of the same law, there will soon be penalties for failing to use electronic health records in hospitals, clinics, and medical practices. To my knowledge, the best result of the HITECH law thus far has been the Care Connectivity Consortium, composed of millions of patients in all fifty states who are part of just five non-profit health systems. It is significant that their effort began before the monetary incentives were enacted, and all five systems were early adopters of electronic records. They have, for example, exceeded HITECH's implementation schedule for 2013, a digital list of a patient's medications. Since CCC is only slightly over one year old, it is too early to know more than anecdotal evidence about patient outcomes, good or bad. It is evident, however, that just system-wide availability of a patient's medications is a major method of preventing bad outcomes from drug interactions. 


Glossary
CCC - Care Connectivity Consortium
EHR - electronic health record
MHR - medical health record
PHR - personal health record
HIT - health information technology
HITECH - Health Information Technology for Economic and Clinical Health (2009 law)
CCHIT - Certification Commission for Health IT (voluntary industry predecessor to HITECH)