1. Incentives for Enhancing Stroke Care Sandra M. Schneider, MD (Chair) Larry B. Goldstein, MD (Co-Chair) James G. Adams, MD Kenneth L. DeHart, M.D Michael D. Hill, MD Andrew M. Demchuk, MD Anthony Furlan, MD Michael T. Rapp, MD, JD Joseph P. Wood, M.D., J.D.

2. Principles & Caveats  Broad-based approach, but  No representation from –Third party payers –Hospital administrators –Primary care providers –Radiologists  Lessons from experience with acute thombolysis

3. Incentives Matrix Medicolegal Financial Medical/Scientific Administrative PayersHealthSystemsNeurologists Emergency Physicians DomainsDomainsDomainsDomains Stakeholders

4. Emergency Physicians Administrative  Over 90% of ED directors perceive their department is either at or over capacity  American Hospital Association- 62% of EDs are at or over capacity  Point prevalence study done on a typical spring evening found –1.1 patients per treatment space –4.2 patients per RN –9.7 patients per physician  Nearly 70% of emergency department care is delivered in ‘off-hours’  Stress in the system for delivery of optimal care

5. Emergency Physicians tPA Experience  Medical/ scientific issues perceived as unresolved  Lack of consultative support for acute stroke treatment (radiological, neurological) is viewed as the most significant barrier  Lack of systems support  Medicolegal risk

6. Emergency Physicians Incentives  Improved consultative resources –Neurology/ radiology –Regional consultative practices Telemedicine/ teleradiologyTelemedicine/ teleradiology –Poison Control Center model  Support development of primary stroke care centers & care systems –Care pathways/ protocols  Address staffing issues –Hospitals/ health care systems –Payers

7. Incentives Matrix Medicolegal Financial Medical/Scientific Administrative PayersHealthSystemsNeurologists Emergency Physicians DomainsDomainsDomainsDomains Stakeholders

8. Neurology Administrative  Limited numbers of neurologists who are concentrated in major metropolitan areas  Many neurologists sub-specialize and may not regularly care for stroke patients –No more than 50% of American neurologists have given IV tPA for acute stroke  General neurologists practice primarily in an outpatient setting –Need to be available to be called during a busy clinic, often off-site

9. Neurology Medical/ Scientific/ Medicolegal: tPA Example  Debate about optimal patients for treatment  In one survey, less than one third (30%) of neurologists found the evidence for tPA efficacy “very convincing”  Many felt the drug was “too risky”  62% were “very concerned” about ICH  Medicolegal concern Neurology 1998;50:1491-1494 Stroke 2001;32:861-865

10. Neurology Financial  Economics of clinical practice dictate a tightly scheduled day  Evaluation of a stroke patient can take several hours  Limited financial reimbursement is a disincentive to leaving a crowded office to provide emergency consultative services  Telephone consultation –Consultants are legally liable for advice given over the telephone –There is no financial reimbursement for telephone consultation  Neurologists frequently interpret radiographic studies such as CT scans to guide treatment –They are rarely financially reimbursed for these activities

11. Neurology Incentives  Training of all new neurologists in stroke care –Paradigm shift  Continue to address medical and scientific concerns  Update current CPT coding with appropriate RVUs for acute stroke, including thrombolytic therapy  Reimbursement for telephone/telemedicine consultations and for interpretation of acute stroke imaging studies by neurologists  Clarify medicolegal liabilities related to acute stroke interventions, including telephone consultations

12. Incentives Matrix Medicolegal Financial Medical/Scientific Administrative PayersHealthSystemsNeurologists Emergency Physicians DomainsDomainsDomainsDomains Stakeholders

13. Health Systems  Support of health systems is critical  Because there may be different payers for acute and long-term care, even if an acute treatment is cost-effective from a societal standpoint, it may increase the costs to those providing the treatment that is not reimbursed (disincentive)  Currently no stroke CMS quality indicators  Little incentive to support stroke QI initiatives

14. Health Systems Incentives  Studies show that having an organized system of care shortens LOS, decreases complications and can reduce costs  CMS will likely reintroduce stroke indicators  Programs to identify stroke centers are being discussed

15. Incentives Matrix Medicolegal Financial Medical/Scientific Administrative PayersHealthSystemsNeurologists Emergency Physicians DomainsDomainsDomainsDomains Stakeholders

16. Medicolegal  Malpractice –Violation of the accepted standard of care resulting in harm to a patient  In court, opinions about the standard of care are provided by one or more experts  The starting point for litigation is often a bad outcome (because the patient had a stroke)

17. Medicolegal tPA Example  Failure to administer –Had it been used, the outcome would have been the elimination of the patient’s neurological deficits –Hard to prove scientifically, but easy to establish in a court of law since it may merely require the opinion of a qualified witness  The administration was either not indicated or improperly administered –Hemorrhage or perhaps simply failure to be cured

18. Fertile Field for Malpractice Litigation  Uncertainty, lack of familiarity, lack of support  Popular press, magazines, and newspaper stories have sometimes overstated the therapeutic potential  Advertisements and websites of malpractice attorneys highlight the “alarmingly low” use of tPA for patients with acute stroke, “especially for African Americans.” 1  “If you suspect that a loved one should have received tPA but did not, or that tPA was administered improperly, it may be important to contact an attorney.” 2  “If you suspect that a loved one should have received tPA but did not, or that tPA was administered improperly, it may be important to contact an attorney.” 2 (1) www.cerebralpalsylegalhelp.com/cerebral/developments.html (2) http://www.injuryboard.com

19. Reducing Medicolegal Risk  Appropriate consultative support  Institutional evidence-based policies for the use of a treatment  Follow accepted guidelines or policy statements by professional organizations

20. Incentives Matrix Medicolegal Financial Medical/Scientific Administrative PayersHealthSystemsNeurologists Emergency Physicians DomainsDomainsDomainsDomains Stakeholders

21. Financial  Facilities reimbursed by governmental payers based on a Diagnosis Related Grouping (DRG) methodology –Largely reflects overhead costs calculated from “case data” with little recognition of the expense of new therapies  Commercial payers typically compensate on a “per diem” basis, with denied payment inconsistency  Physician payment based on CPT codes (E&M Codes) –CPT code for IV tPA for acute stroke (37195), the work RVU is 0 –Concurrent care may not be reimbursed (disincentive to team approach)  Financial support for stroke systems lacking

22. Payers Incentives to Improve Care  Recognition of the added value of supporting stroke care systems –Support medical leadership and system analysis (QI programs)  Reimbursement must reflect the increased costs to institutions providing new interventions  CPT-Code revision –Redefine existing codes (37195) –Develop specific new codes for acute stroke care –Advocate against restrictions based on concurrency of care –Support telephone consultation (codes exist, not paid)  Support telephone consultative centers (Poison Center Model)  Patient & professional groups need to advocate for change

23. The Bottom Line

24. Summary of Incentives -1  Support the development and maintenance of stroke care systems  Provide acute stroke consultative support (especially neurological and radiological expertise) for ED physicians and non-specialist care providers through in-hospital protocols and systems approaches, including telemedicine consultation and teleradiology as appropriate

25. Summary of Incentives -2  Develop a coordinated stroke reimbursement strategy involving patient advocates and professional organizations  Define medicolegal issues in order to reduce physician liability risk related to the provision of innovative acute stroke care  Support outcomes assessment programs to inform quality improvement efforts and dissemination of best practices

26. Summary of Incentives- 3  Assure that appropriate education is conducted and that consensus is achieved as new therapies are introduced. Educational priorities include emergency caregivers, neurologists and nursing staff  Provide forums for constructive dialog among emergency physicians, neurologists and other key stroke care providers  Continue to refine and advance the level of stroke care through clinical research

27. Incentives Matrix Emergency Physicians NeurologistsHealthSystemsPayersAdministrative Medical/Scientific Financial Medicolegal DomainsDomainsDomainsDomains Stakeholders