Has QI become a convenient smoke screen for cost cutting?
Has QI become a convenient smoke screen for cost cutting?
Promoting savings ahead of improvements leads to abuses
Within two years of most insurance companies and managed care organizations (MCO) mandating a 24-hour maternity stay, President Clinton last September signed legislation requiring reimbursement for a 48-hour length of stay (LOS) for insured mothers and newborns. Press stories about ill or dying babies gave lawmakers an irresistible cause, despite MCO and hospital assurances that the one-day stay was a result of quality improvement efforts.
Similarly, in August, when Connecticut surgeons protested a consultant’s recommendation that insurers require outpatient mastectomies, the stage was set for yet another public revolt. Managed care companies rushed to defuse the situation by publicly opposing the recommendation, fearing the state legislature would again step in. Once more, a change in treatment, ostensibly prompted by quality improvement, was thwarted.
Then in early December, the Health Care Financing Administration (HCFA) told 300 MCOs they could not restrict what advice participating doctors give to Medicare patients. And even though some MCOs had already endorsed the HCFA position, President Clinton has said legislation to outlaw the "gag clauses" would be an administration priority.
Some MCOs have miscalculated
What’s going on here? If these are truly quality improvements justified by clinical evidence, why are health care organizations apparently backing down? Where did they miscalculate?
Calculation may be the key word when discussing quality improvement and cost-cutting efforts. Successful quality improvement efforts frequently do lower health care costs. But somewhere along the way, the waters have become muddied, and cost cutting has become paramount in quality efforts.
QI professionals boast of clinical pathways, protocols, and other projects that have improved quality of care. However, the quality improvement message is often secondary to cost savings. Mimicking hospital administrators who are under immense pressure to lower costs and increase margins, QI managers instinctively point to cost savings and lower LOS to justify their projects.
"The real question is, on an evidence basis, what’s the best answer?" asks James Espinosa, MD, FACEP, FAAFP, director of quality improvement with Emergency Physician Associates in Woodbury, NJ, and emergency department physician at Overlook Hospital in Summit, NJ. "On a scientific basis do we know anything that allows us to stratify who can go home immediately after normal delivery and who needs to stay a couple of days? We don’t know a whole lot about these things, so we end up getting into emotional arguments for or against.
"Unfortunately, you’ll hear a lot of people say we made this intervention, and we haven’t seen any bad outcomes.’ When you ask them what they’re looking for and how they’re doing it, very often you find out the science is pretty weak," says Espinosa. "We’re talking about large health care dollars and very important events. And in many cases, the randomized clinical trial, which is the gold standard of understanding these outcomes, is not being implemented."
Kicab Castaneda-Mendez, president of aejes Seminars & Consulting in Ridgefield, CT, and author of Value Based Cost Management for Healthcare: Linking Costs to Quality and Delivery, says there are three kinds of processes: business value-added, patient value-added, and employee value-added. "If we use length of stay and costs, which are business value-added measures, to measure quality improvement, which is a patient value-added process, we risk subtracting value to the patient," he says.
If a quality improvement project addresses failures and reduces variability in the system, LOS and costs will go down, he stresses. Because the patient value-added measure patient satisfaction was left out of the maternity one-day stay equation, there was such severe backlash Congress had to get involved, Castaneda-Mendez observes.
Granted, some teams point to flat mortality, lower inpatient complications, or readmission rates, as well as decreased costs and LOS. But this data is not proof that their QI projects were successful.
For example, in the case of newborn deliveries, how many new mothers phoned or saw their pediatricians or obstetricians with questions or complications? How many quit unsupported efforts to breast-feed? Most QI teams that built one-day stay pathways can’t answer these questions, several QI/TQM sources speculate.
Who’s going to fight for the little guys?
"So many people [QI professionals] have to justify their existence, and it’s only going to get worse with capitation," says Janice Schriefer, RN, MSN, MBA, CCRN, director of outcomes management at Butterworth Hospital in Grand Rapids, MI. "It’s scary that [the one-day stay issue] had to go to the legislative level. It hasn’t even gotten bad yet. What about populations that aren’t as big, that don’t have as big a voice? I think it’s going to get really ugly."
The key, Schriefer says, is finding out "how low you can go" cost-wise without having a negative impact on quality. The trick, she says, is to eliminate parts of the care process that don’t add any value. Study the literature to learn about the results of randomized clinical trials, she says.
When the research doesn’t exist, ensure what you’re cutting are nonvalue-added activities by cutting one thing at a time and measuring outcomes, she advises. Unfortunately, this process takes time, while QI professionals are pressured to show results quickly. Administrators screaming about continuous quality improvement (CQI) taking too long have fueled the fire of drastic cost cutting. "When costs aren’t your main driver, CQI should take a long time," Schriefer asserts.
Pediatricians were instrumental in getting the two-day maternity stay legislation passed because they were overwhelmed with calls from new moms. The costs that were driven out of the inpatient stay in many cases were merely shifted to another time period along the continuum of care.
The unforeseen frequently hurts quality
Sometimes good intentions go awry, Schriefer says. For example, in an attempt to reduce joint replacement surgery costs, her hospital proposed using only three prosthesis vendors instead of 10. This would provide a 50% discount. Upon further investigation, the team determined that switching to different products would cause expensive operating room time to escalate. As the length of the operation increases, so does blood loss, pain, and infection rates. And using an unfamiliar prosthesis could cause physicians to make an error in leg length. Limiting the number of vendors also could mean that the prosthesis best for a particular type of patient be it a big burly factory worker or a petite elderly woman might not be available.
"A lot is riding on this cost issue," Schriefer says. "You’re talking about whether someone can walk well for the rest of his or her life, or not."
Espinosa tells the story of a hospital on the West Coast that cut intensive care LOS by 1.7 days. It turned out that overall costs actually rose as the hospital saw more returns to the ICU and longer stays in the step-down unit. "It may be more efficient to actually have a longer length of stay," he proposes. "We just don’t know."
As hospital networks get more sophisticated and can gather more accurate data, the ability to integrate cost outcomes with medically related quality outcomes will balance competing interests patient satisfaction, quality of life, clinical outcomes, and costs.
"In the past we’ve always managed them separately. With the increasing sophistication of data, you can see how they touch each other. If you mess with one, you’re messing with the other," Espinosa says. He urges QI professionals to learn all they can about epidemiology and statistical tools like statistical control charts, multiple regression analyses, and designed experiments.
Cost cutting and quality can be balanced only within a data collection/outcomes measurement/case management infrastructure, an infrastructure already in place at many MCOs. If your hospital is involved with an MCO, contact its QI department to see how you can access its data. Get involved with projects like the Maryland Quality Indicator Database, which is open to hospitals nationwide, Schriefer advises.
[For more information, contact James Espinosa, MD, director of quality improvement, Emergency Physician Associates, 307 S. Evergreen Ave., Woodbury, NJ 08096. Telephone: (609) 848-3817. Janice Schriefer, director of outcomes management, Butterworth Hospital, 100 Michigan Ave., NE, Grand Rapids, MI 49503. Telephone: (616) 391-2974. Kicab Castaneda-Mendez, President, aejes Seminars & Consulting, 84 Old S. Salem Road, Ridgefield, CT 06877. Telephone: (800) 291-2974.]
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