June 18, 2004

National Committee On Vital And Health Statistics

Workgroup on Quality

June 24-25, 2004 Hearing

Testimony regarding candidate recommendations:

1. Create a mechanism for reporting selected inpatient and outpatient laboratory results in a standard transaction.
2. Create a mechanism for reporting selected vital signs and objective data measurements for inpatient encounters and outpatient visits in a standard transaction.
3. Facilitate the reporting of a diagnosis modifier to flag diagnoses that were present on admission on secondary diagnosis fields in all inpatient claims transactions.
4. Modify the usage instructions for the existing data element for Operating Physician such that it is a required data element for the principal inpatient procedure.
5. Modify the requirements for reporting Admission Date/Time and selected Procedure Dates/Times on Institutional claims transactions.
6. Encourage payers to modify billing instructions to providers to align procedure start and end dates with services included in selected global procedure codes in standard HIPAA claims transactions.
7. Review the available options for coding patients’ functional status in EHRs & other clinical data sets and recommend standard approaches. Conduct the research recommended by NCVHS in 2001 and CHI in 2003, as endorsed by NCVHS.
8. Create a mechanism for reporting functional status codes in a standard transaction

These candidate recommendations are strategically very important to improving patient care in our country.  Every effort possible should be made to ensure they become standard practice.

Candidate recommendations 1 & 2:

This would greatly enhance ability to systematically improve the health outcomes and obtain better value from health care expenditures.  Intermediate outcomes of care such as lab results and vital signs are the foundation of disease management and population health improvement.  Their availability would enable:

• Tailored interventions for individual patients.
• Patient level health interventions outside the office visit setting.
• Defining accountability for improving patient outcomes.
• Developing incentives (pay for performance) for outcomes for providers and health plans.
• Developing incentives for patients.
• Providing disease management interventions at far less expense than is now possible. 
• Currently medical records of the entire population (diabetes, coronary artery disease, etc) must be reviewed to obtain this information for one point in time.  Reassessment relies on patient report or re-review of records. The most intense disease management interventions are typically limited to a subset of the population due to resource constraint.  Many patients would benefit from greater support that is currently cost prohibitive.  The cost benefit ratio of any targeted intervention would be expected to improve significantly.
• Obtaining CMS, state (mandated) and accreditation required performance measures such as HEDISâ hypertension control requiring chart review.
• More reliable outcome information based on full population performance, not samples.
• Reporting of composite patient level outcomes such as % of patients meeting all treatment targets that assess ‘systems’ of care.
• Assessment of patient outcomes by any level of the health care system-patient, provider, clinic site, provider group, health plan or hospital.
• Enhanced continuity of care through the routine sharing of this information.
• Preventing duplication of services thereby decreasing waste of health care dollars.
• Population level information could be evaluated for correlation with claims based outcomes that would enhance our understanding of the relative importance of improving specific clinical variables.
• Tobacco use status, including pediatric passive exposure to tobacco smoke, should be treated as a vital sign in regards candidate recommendation #2.

Candidate recommendations 3, 4, 5 & 6:

This would greatly enhance ability to systematically improve patient safety and obtain better value from health care expenditures. Their availability would enable:

• Risk adjustment of hospital and provider outcomes based on pre-existing patient characteristics
• Better understanding of volume thresholds required to achieve best patient outcomes
• Assessment of patient outcomes by hospital and provider
• Correlation of outcomes to specific patient characteristics including information noted in candidate recommendations 1 and 2.
• Cost effective assessment of hospital care for time to specific intervention measures such AMI time to open vessel and CAP time to antibiotics.
• Assessment of efficiency of hospital care for many diagnoses requiring procedural intervention.  Time to intervention for patients admitted through the emergency room for appendicitis, cholecystitis, fracture, etc.
• Developing incentives (pay for performance) for outcomes for providers, hospitals and health plans.

As a point of clarification regarding global procedure codes on page 29, paragraph two:

The HEDIS post-natal visit measure requires a visit between 2 and 8 weeks following delivery.  We find patients delivering by cesarean section are being seen by their provider prior to two weeks and after 8 weeks post-partum.  Thus the statement is not completely accurate as written.

Candidate recommendations 7 & 8:

Functional status is an important means of assessing health care quality and outcomes.  Every effort should be made to systematically capture and use patient functional status.

It would be possible to:

• Determine the effectiveness of interventions done to improve patient functional status such as total joint replacement surgery.
• Compare functional status outcomes by provider, hospital and health plan.
• Assess procedures for positive, neutral or negative functional outcome improvement across full populations of patients
• Use real world functional status outcomes information to inform benefit and network design.

These comments summarize a few of the benefits that would be gained with candidate recommendations 1-8.  All recommendations would be highly beneficial in my opinion.  Significant benefit would be derived from moving the recommendations forward either individually or in combination.

Respectfully submitted,

/s/

Gail M. Amundson, M.D., F.A.C.P.
Associate Medical Director of Quality Improvement
HealthPartners
PO Box 1309
Minneapolis, Minnesota 55440
Telephone:  952-883-5378
Fax:  952-883-5310
E-mail:  Gail.M.Amundson@HealthPartners.com