Report Cards & Reputational Incentives  Why fewer providers?  Medicare covers health services that are “reasonable and necessary.”  “In reality, many.

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Presentation transcript:

Report Cards & Reputational Incentives  Why fewer providers?  Medicare covers health services that are “reasonable and necessary.”  “In reality, many new procedures are paid for even with no persuasive evidence of benefit.”  For example: Cardiac CT angiogram Rita F. Redberg and Judith Walsh: Pay Now, Benefits May Follow — The Case of Cardiac Computed Tomographic Angiography. N Engl J Med 2008; 359(22): ; Julie M. Miller, Carlos E. Rochitte, Marc Dewey, et al.: Diagnostic Performance of Coronary Angiography by 64-Row CT. N Engl J Med 2008; 359(22):

Report Cards & Reputational Incentives  CMS wants to provide reimbursement in such a way that it can “avoid unnecessary costs.”  Accordingly CMS will likely increase the scope of its provider report cards Berry M Straube. Towards a value-based Model: Pay for Reporting/Performance Initiatives in the Medicare Program. June 7, 2007; (28 Nov 2008);

Report Cards & Reputational Incentives  Reason: over utilization of health care  Bureaucrats have a hard time determining medical necessity  Report cards make MDs think twice  A “kill them all” approach to health care spending

Report Cards & Reputational Incentives  Me, paranoid?  Ken Kizer’s Comment  IOM:  “remove” MDs who do not play be the rule  (“Re-education” may be offered to some) Institute of Medicine: Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: National Academy Press, See also Thomas R. McLean: Application of administrative law to health care reform: the real politik of Crossing the Quality Chasm. 16(1) J Law Health 65, (2002).

Report Cards & Reputational Incentives  Secondary RIs  Reversal of the brain drain –German MD model –Paradoxically US-MDs forced from the market may tx American patients  Medical tourism  Telemedicine Will reputational incentives stimulate a reversal of the physician brain drain. J Health Serv Res Policy 2008; 13(1): 50-2.;

Report Cards & Reputational Incentives  Secondary RIs –Someone is to blame –Misclassification of services occurs frequently; no plans to audit data –RI will lead to “gaming” lawsuit: Allege that economic competitors “cooked the books” David M Shahian, Thomas Silverstein, A Lovett, et al.: Comparison of clinical and administrative data sources for hosptial coronary artery bypass graft surgery report cards. Circulation 2007; 115: See also Thomas J Ryan: To Understand Cardiac Surgical Report Cards Look Both Ways. graft surgery report cards. Circulation 2007; 115: See also Thomas J Ryan: To Understand Cardiac Surgical Report Cards Look Both Ways. Circulation 2007; 115:

Report Cards & Reputational Incentives  Secondary RIs –Legitimate lawsuit ? –Still legal and political pressure many require audits –Traditional audits  could be expensive  Increase fear?

Report Cards & Reputational Incentives  Better living though technology  EMR as a Trojan house –The narrative tells the tale the provider you to hear –The metadata tells you the truth

Report Cards & Reputational Incentives EMR System Metadata –Automatic & Necessary for EMR function –Examples UPINs (digital fingerprints) Time-signature (time & motion studies) McLean TR, Burton L, Haller CC, McLean PB: Electronic medical record metadata: uses and liability. J Am Coll Surg. 2008; 206(3): ; McLean TR, Burton L, Haller CC, et al., Surgery Clinic: Tragedy of the Commons, Presentation at 32nd Annual Meeting of AVAS, Dallas TX, May 5-7, 2008; Graphic from:

Report Cards & Reputational Incentives EMR Application Metadata –Audit trail of user modification –Limited storage: cost v other safeguards Sedona Conference: Commentary on ESI Evidence and Admissibility, March 2008; URL available on request.

Report Cards & Reputational Incentives Metadata is searchable

Report Cards & Reputational Incentives  “Voluntary” RI integrity audits –Condition of payment  Access to EMR & EMR metadata  Sampling paradigm –A future driver of False Claims actions?

Report Cards & Reputational Incentives  Summary: –Report Cards create RIs –RIs  do change provider behavior  Potentially fewer providers in the market  Increase fear ?

Report Cards & Reputational Incentives  Longview of RIs –“Do we really want doctors who are motivated by wall plaques announcing their score on some ‘quality improvement’ initiative?” Mark Vonnegut: Is Quality Improvement Improving Quality? A View from the Doctor’s Office. N Engl J Med 2007; 357(26): raj/awards/HPCS2004Certificate.jpg

Report Cards & Reputational Incentives  Longview of RIs –Report cards “that rate doctors against one and other, [and will make them] increasingly dependent on quality improvement goals and payments while distracting them from patient care.” –What would Marcus Welbe, MD do? M ar k Vonnegut: Is Quality Improvement Improving Quality? A View from the Doctor’s Office. N Engl J Med 2007; 357(26):

Report Cards & Reputational Incentives  NEJM Editorial’s Bottom line: –“Public report cards are not going away.” –Neither are RIs Robert Steinbrook: Public Report Cards-Cardiac Surgery and Beyond. N Engl J Med 2006; 355(18):

Thank you for listening