Robert A. Berenson

Lost in Transition: Challenges and Opportunities for Improving the Quality of Transitional Care

As national awareness of medical errors and quality deficiencies that occur within particular care settings continues to rise (1), an expanding evidence base points to similar problems that occur during care transitions. Transitional care has been defined as a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care in the same location (2). Although a comprehensive review of this literature is beyond the scope of this article, we used the following search terms in MEDLINE (1990 to present) to identify the most relevant articles: transitional care, care transition, care coordination, care transfer, continuity of care, and hospital discharge. Most articles retrieved are predominantly descriptive and focus on patients care needs during transitions. Few provide evidence-based suggestions for physicians; however, a consensus conference attempted to identify key roles for the sending and receiving care team (3), and a recent report details best practices for transitional care in managed care organizations and includes programs in which physicians have substantial roles (4). In contrast, controlled studies show compelling evidence that management of transitional care by advance practice nurses can reduce rates of rehospitalization for patients with congestive heart failure and for older patients with complex care needs (5-10). Quantitative evidence increasingly indicates that patient safety is jeopardized during transitional care. Medication errors pose a significant threat to patients undergoing transitions (11-14). Receiving care in multiple settings often means that patients obtain medications from different prescribers (15). Rarely do clinicians have complete information with which to monitor the entire regimen adequately, much less intervene to reduce discrepancies, duplications, or errors. Forster and colleagues found that 19% of patients discharged from the hospital experienced an associated adverse event within 3 weeks (16); 66% of these were adverse drug events. Another study examined 30-day posthospital care patterns in a nationally representative sample of Medicare beneficiaries. Between 12% and 25% of all care patterns were categorized as complicated, requiring the patients return to a higher-intensity care setting (17). Qualitative studies have consistently shown that patients and their caregivers are unprepared for their role in the next care setting, do not understand essential steps in the management of their condition, and cannot contact appropriate health care practitioners for guidance. Many patients and caregivers are frustrated by having to perform tasks that their health care practitioners have left undone (18-22). Challenges to Improving the Quality of Transitional Care Challenges to improving the quality of care transitions occur at multiple levels. The barriers to improving transitional care are discussed in depth elsewhere (23). Since many transitions are urgent and unplanned, patients are largely unprepared for what transpires and are often uncertain about their role. Those in institutional settings often adapt to the environment by becoming dependent and complacent while their needs are being addressed; however, upon discharge to home, patients and family members are abruptly expected to assume a self-management role in the recovery of their condition, with little support or preparation. No longer does one practitioner typically take responsibility for orchestrating the core functions of the sending and receiving teams during a care transition. This is exacerbated by a growing national trend wherein practitioners limit the scope of their practice to a single setting (24, 25). Furthermore, many of the professionals involved in transitional care have never practiced in the settings to which they are sending patients. Accordingly, they are often unfamiliar with the capacity of these settings for delivering care and may transfer patients inappropriately. Effective care transitions depend on collaboration across health care institutions; however, institutions often function in isolation, and there is no way to assign responsibility when problems arise (23, 26). Although vertically integrated organizations are better able to facilitate effective transfers (27), vertical integration based around hospitals is waning (28). Moreover, because of problems with overcapacity, hospitals are more frequently diverting patients to care settings where their personal physician does not practice and previous medical records are not available (29, 30). The patients database has to be recreated, with the potential for serious errors. Widespread implementation of a universal electronic health information system with connectivity across settings does not appear to be imminent. Few health delivery systems have access to an electronic health information system, and even fewer have a system with connectivity beyond the hospital, clinic, or office (31-33). Current payment mechanisms are generally perceived as providing little financial incentive for collaboration across sites, further reinforcing the silos of care. Furthermore, institutions and physicians assume minimal financial risk for ensuring that patients posthospital care needs are addressed. Most prevailing payment approaches other than capitation do not exact financial penalties on providers for inappropriate discharges or transfers. Payment policies for physicians rarely include reimbursement for activities specific to facilitating the sending and receiving of a patient in transfer. Rather, these activities are subsumed, for the most part, under routine evaluation and management codes involving face-to-face contact with a patient. Developing an Action Agenda The first step to improving the quality of transitional care is to recognize and address the unique attributes of this domain of health care. Complementing recognition is the need for system-level performance measurement. Process measures are particularly well suited to measuring transitional care and have the added advantage that they may not require formal case-mix adjustment techniques. Process measures might be used to address the extent to which patients are prepared for a care transfer, whether the appropriate information is promptly transmitted, and whether pre- and post-transition care regimens are reconciled to reduce redundancy and prescribing errors. Several process measures that assess transitional care from the perspectives of both the health care system and the patient have been developed (34-36). These types of measures for transitional care need to be incorporated into national performance measurement initiatives. Steps to promote better transitional care also need to be taken at the oversight level. In particular, Medicare Conditions of Participation address select issues of transitional care but are not adequately enforced. Medicare relies on the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to determine whether hospitals have satisfied Conditions of Participation (37). This assessment must extend across settings and must be expanded to determine whether the appropriate information was received in a timely fashion and whether patients were prepared for care in the receiving institution. Payment policies need to be modified to include financial incentives that would promote effective care transitions. One approach would be bundling acute and postacute care services for a distinct episode of care, as the Centers for Medicare & Medicaid Services (CMS) has successfully demonstrated for the management of coronary artery bypass grafting (38). Bundling would probably counteract the silo mentality by creating a tangible incentive for practitioners in different institutions to communicate, share information, and perhaps identify the most appropriate sequence of transfers during the formulation of a patients overall care plan. Practitioners might, for example, determine that an additional 1 to 2 days of rehabilitation in the hospital would obviate an entire transition to a skilled-nursing facility. The physician payment system needs to more explicitly recognize the work associated with facilitating patient transitions. Codes within the Healthcare Common Procedure Coding System (39), including certification and oversight for patients in home health and hospice, could serve as a model. The Centers for Medicare & Medicaid Services and other payers should encourage physicians to devote more attention to transfers by implementing a payment code for completing a well-defined and auditable set of activities that promote high-quality care transitions, such as developing and discussing a transfer plan with patients, caregivers, and other relevant health care professionals (including those from the receiving institution). This code would replace the nondefined discharge day visit that physicians currently use. Finally, because payers deal directly with the consequences of poor transitions, they should include attention to transitions in developing efforts to pay differentially for performance (that is, pay for performance) (40), particularly since individual providers may face perverse incentives and barriers to taking on full responsibility for assuring effective transitions. Summary and Next Steps Quality problems have been grouped into 3 categories: underuse, misuse, and overuse (41). Poor transitions generally reflect misuse, and, as such, efforts to improve transitions might actually save money by preventing expensive avoidable complications that result in rehospitalizations or extended postacute care stays. Smoother transitions could also decrease costs associated with the performance of redundant diagnostic tests. In contrast to many other quality problems in health care, the problems associated with poor transitions can be addressed within current spending levels and w

Clarifying Sources of Geographic Differences in Medicare Spending

BACKGROUNDnAlthough geographic differences in Medicare spending are widely considered to be evidence of program inefficiency, policymakers need to understand how differences in beneficiaries health and personal characteristics and specific geographic factors affect the amount of Medicare spending per beneficiary before formulating policies to reduce geographic differences in spending.nnnMETHODSnWe used Medicare Current Beneficiary Surveys from 2000 through 2002 to examine differences across geographic areas (grouped into quintiles on the basis of Medicare spending per beneficiary over the same period). We estimated multivariate-regression models of individual spending that included demographic and baseline health characteristics, changes in health status, other individual determinants of demand, and area-level measures of the supply of health care resources. Each group of variables was entered into the model sequentially to assess the effect on geographic differences in spending.nnnRESULTSnUnadjusted Medicare spending per beneficiary was 52% higher in geographic regions in the highest spending quintile than in regions in the lowest quintile. After adjustment for demographic and baseline health characteristics and changes in health status, the difference in spending between the highest and lowest quintiles was reduced to 33%. Health status accounted for 29% of the unadjusted geographic difference in per-beneficiary spending; additional adjustment for area-level differences in the supply of medical resources did not further reduce the observed differences between the top and bottom quintiles.nnnCONCLUSIONSnPolicymakers attempting to control Medicare costs by reducing differences in Medicare spending across geographic areas need better information about the specific source of the differences, as well as better methods for adjusting spending levels to account for underlying differences in beneficiaries health measures.

Medicare's Readmissions-Reduction Program — A Positive Alternative

The Affordable Care Acts financial penalty for “excessive” readmissions may be too weak to overcome the substantial counterincentives currently at work. But a “warranty” payment would provide a stronger business case for hospitals to get with the program.

Ethical Practice in Managed Care: A Dose of Realism

Medical ethics and medical economics are increasingly in conflict. In response to the ascendance of managed care, many ethicists and physicians continue to assert the traditional ethic that physicians should not engage in bedside rationing or should not be motivated to do so through the application of financial incentives [1-8]. Meanwhile, health maintenance organizations (HMOs) and integrated provider groups are implementing incentives that reward physicians for providing fewer services [9-11]. The approach to financial compensation that ethicists recommend most highly-incentive neutrality [7, 12] -is most easily accomplished through salaried compensation; this, however, is the very approach that many managers of care reject, precisely because salary sends no signals about appropriate physician behavior in an era of constrained resources [13]. It is untenable for the medical profession to continue asserting an idealistic ethic that is contradicted so openly in daily practice. However, a satisfactory ethic appropriate to the managed care era has not yet been developed to replace the traditional ethic. Many in the profession have not come to terms with the conflicting expectations they now face and so feel caught in a moral crisis. In this article, we begin to map a way out of this dilemma. We do so by building on the work of others before us who have proposed new ethical principles that are more attuned to the physicians role in an era of managed care [8, 14-29]. We synthesize this previous work and add important refinements and insights. We also more fully articulate the theoretical framework within which to construct managed care ethics. In so doing, we strive for a set of realistic principles that will restrain the potential abuse inherent in the new incentives and are compatible with the roles and structures taking shape in actual managed care organizations. Our goal is to offer recommendations for clinical practice and for public policy discussions that accept the reality of physicians participation in common forms of managed care, not to frustrate the entire enterprise. We accept, but do not attempt to justify, the forms of managed care in common use. Some physicians, ethicists, and consumer advocates continue to resist the revolutionary changes in the structure and financing of health care delivery. We are among those who welcome many, but not all, of these changes. In our view, rationing, defined broadly as resource allocation, is necessary and inevitable in some form, and bedside rationing (defined as individual physicians declining to administer beneficial treatments because of costs to someone other than the patient [30]) is usually preferable to centralized, rule-based rationing. Rationing through central (bureaucratic) rules has desirable attributes, including evenhandedness, visibility, and predictability, that recommend its use in some situations, but bedside rationing tailors spending decisions to the circumstances of each patient. It also operates through incentives to professionals rather than through bureaucratic authority. Bedside rationing is more acceptable when patients choose their insurance knowing that their coverage plan uses financial incentives to encourage physicians to economize in order to decrease premiums or expand benefits [31, 32]. When given the choice, subscribers may prefer bedside rationing to other cost-control strategies that lodge authority for making clinical decisions with insurance companies or other organizations external to the practitioner-patient relationship. The obvious problem with this justification is that the critical ethical foundations for meaningful choice are often lacking in the existing marketplace. Many HMOs conceal from subscribers the incentives and other mechanisms that may affect their physicians judgments. Even worse, a few HMOs impose gag clauses that keep physicians from discussing their compensation terms and the HMOs utilization guidelines [33]. In addition, many subscribers have little choice over the kind of insurance they receive [34]. We strongly support efforts to correct these defects through voluntary or regulatory action. Other desirable protections against potential system abuses include limiting the ability of health plans and providers to select only patients with good risks (cherry pick), providing useful outcome measures of plan and practitioner quality of care, and offering patients efficient procedures for airing grievances and appealing coverage denials [35-39]. However, while we wait for this improved version of managed care to evolve, physicians need practical guidance in the existing, imperfect world of clinical practice on how to make bedside rationing ethically acceptable. Managed care, despite its imperfections, cannot be made to disappear, nor can physicians be expected to plunge into the brave new world of bedside rationing without ethical guidance. Any statement of ethical guidelines is necessarily grounded in an ethical framework. Yet, it is impossible in the space available to justify our framework and defend it against all contenders. The most we can do is make our starting premises explicit so that those who disagree can more clearly identify why. On the basis of these premises, we offer several concrete guides for physician attitudes and behavior. Medical Ethics Is Aspirational and Role-Based For the most part, medical ethics is contingent on physicians role in society. In contrast, a universal or absolutist ethic remains the same for all times and all circumstances. Although medical ethics has important universal components because of its focus on human illness, the institutional and financial dimensions of medical ethics are more contingent. The manner in which physicians are employed and paid are issues that medical ethics can help influence but cannot determine. Politics and economics create and define the professional role that medical ethics must respond to. Role-based professional ethics help physicians act in the most socially useful manner; as such, they depend narrowly on the precise instrumental connection between the particular behavior in question and the role that society intends for physicians [40]. These justifications do not often generate sweeping and absolute generalizations that spring axiomatically from fundamental premises. We also believe that many ethical rules are aspirational, not regulatory. They set ideal end points toward which imperfect humans strive but are not expected to reach fully [41, 42]. This view of ethics finds its most powerful modern statement in the resurgence of virtue ethics, which attempts to improve moral character by focusing on desirable psychological traits and attitudes rather than on concrete rules of behavior [43]. This view is also captured in a more pragmatic strain of ethics known as rule instrumentalism, which looks to the behavioral effect of ethical rules rather than reasoning deductively from first principles. A proposed ethical rule is good if it tends to produce desirable behavior and attitudes, even if complete and literal adherence is unrealistic or unwise. Instrumentalism is not equivalent to utilitarianism. Whether or not resulting behavior is desirable can be evaluated in nonutilitarian ethical and political terms; our thrust is to design ethics that are based on actual effects rather than on abstractions or theoretical absolutes. Rule instrumentalism accepts inherent tensions and outright contradictions between what physicians profess and how they act, so long as cynicism does not become so widespread that it destroys the beneficial ethos. Traditionally, we have tolerated a sharp dissonance between medical ethics professed adherence to a rule of absolute patient loyalty and the reality of myriad violations of the rule [44]. For example, physicians routinely make pragmatic decisions in public institutions operating under fixed budgets that may compromise individual patients optimal medical benefit. In clinical practice, physicians regularly compromise individual patient welfare to a small but discernible extent because of competing demands for their time and limits on available specialized facilities and technology. They also comfortably adopt prudent clinical heuristics that avoid extravagant expenditures for very small increments of medical benefit. Nevertheless, physicians profess a strong ethic of providing optimal patient care. The fact that undivided loyalty to patient welfare is sometimes given only lip service illustrates that, to the extent that ethical maxims are justified primarily by their instrumental function, this function is not necessarily destroyed by observing actual violations. Patient Trust Is the Primary Focus We further believe that the primary goal of role-based medical ethics should be the preservation of patients trust in their physicians. Trust is important primarily because of its therapeutic role, not simply because of its intrinsic, theoretical value. Therefore, the critical tests for ethical compromises should be whether they undermine patients willingness to seek treatment, disclose necessary information, and comply with treatment recommendations-not simply whether in the abstract they tend to increase a general sense of unease or erode the justification for trust. This is an intensely empirical inquiry about which there is much speculation but few data or even anecdotes. Some opponents of financial incentives overstate their case because they assume a psychological basis for trust that is far too fragile. They believe that patients cannot trust their physicians unless tough legal and ethical constraints are placed on physicians authority. Instead, trust in physicians may be capable of withstanding many assaults, given the intense need for trust caused by patients dependence on physicians skill and judgment when patients have a serious illness [45-48]. Paradoxically, trust may be most indefatigable w

Medical Savings Accounts

The American College of Physicians remains committed to achieving universal health insurance coverage. Medical savings accounts (MSAs) have been proposed as a supplemental mechanism for financing health care services. Medical savings accounts could be used to accumulate funds for health care expenditures just as individual retirement accounts (IRAs) accumulate funds for retirement. Changes in the Internal Revenue Service (IRS) Tax Code would be required to permit tax-deductible contributions by employees and employers to MSAs and to allow interest and earnings to accumulate without taxation. Funds could be withdrawn without penalty only for medical expenses, for the purchase of health or long-term care insurance, or for other expenditures that could be stipulated in the tax code. Each person would own and control his or her account, regardless of changes in employment, and would therefore have a financial incentive to make cost-effective use of health care resources. Coupled with high-deductible health insurance, MSAs could empower cost-conscious patients in health care decision making, increasing competitive pressures to reduce health care costs. Administrative costs and paperwork associated with health insurance might also be reduced, and some persons who currently do not have health insurance might be able to obtain some financial protection. However, MSAs alone will not achieve the goal of universal access. The College is concerned that MSAs may not help unemployed persons or low- and middle-income persons who cannot afford to contribute to such accounts. These accounts may result in reduced health insurance protection and greater out-of-pocket expenses for those most in need of health care services. Problems of adverse risk selection could arise if healthy persons choose to establish MSAs and obtain high-deductible health insurance; this choice would cause premiums to become less affordable for persons who desire traditional health insurance. Consequently, the College favors legislation that would permit experimentation and examination of MSAs through research and demonstration projects that would carefully monitor the effects of MSAs and minimize their potential negative consequences. What Medical Savings Accounts Are Medical savings accounts are tax-free or tax-deferred bank or personal savings accounts that can be used by individual persons and families to pay for their health care expenses. Also known as health savings accounts, medical IRAs, or Medisave accounts, MSAs are viewed as a way to restore individual control over health care expenditures by linking such expenditures directly to a personal medical bank account. Proponents of MSAs argue that such accounts would encourage consumers to use routine health care services more economically because unused funds would accumulate in the account and could be used for future health care needs without restriction. Individual persons and families would therefore have a financial incentive to use routine health care services prudently. Young, healthy persons and other members of low-risk groups who might not otherwise purchase health insurance or save for future health care expenses would have an incentive to make tax-free contributions to their own tax-sheltered MSA. Restoring consumers cost-consciousness and their control over routine health care spending is seen by proponents of MSAs as the most effective way to reduce health insurance costs and overall health care spending, thereby improving access to health care services [1-3]. Existing tax laws do not permit the type of tax-free savings accounts envisioned by advocates of MSAs. The concept of MSAs as discussed in the literature is only a proposed way for individual persons and families to pay for health care. Medical savings accounts are tax-free personal savings accounts from which withdrawals can be made, without penalty, only for medical expenses as defined by the IRS. Federal and state legislative action to amend the tax laws would be required if contributions and interest earnings are to be sheltered from taxation. Current federal income tax laws treat contributions to MSAs by employers as taxable income to the employee; any interest earned in an MSA is also considered to be taxable income. What Medical Savings Accounts Are Not A few employers are experimenting with arrangements that are similar to MSAs. Currently, employers can establish flexible spending accounts that allow employees to have pre-tax dollars withheld from their paychecks to pay for anticipated medical expenses. Funds can be used for medical expenses (as defined by the IRS) but must be used during the same calendar year in which they are withheld. Unused funds cannot be accumulated from year to year and are forfeited to the employer or plan administrator to offset administrative costs. Consumers must spend all of the money in these accounts by the end of the year or forfeit it; such accounts cannot be used to save for future health care expenses. Some employers (for example, Forbes, Dominion Resources, and Quaker Oats) have adopted programs that reward employees with year-end cash bonuses for not submitting health insurance claims or for having claims that are less than an annual target amount [4, 5]. In 1993, the United Mine Workers negotiated a contract in which they agreed to exchange a health insurance plan with no deductible for one with a

Grading a Physician's Value — The Misapplication of Performance Measurement

1000 annual deductible. In return, each employee received a taxable

Revisiting E&M Visit Guidelines — A Missing Piece of Payment Reform

1000 bonus at the beginning of the year, and the employee kept any unspent money at the end of the year [2]. These arrangements are often cited as successful examples of how MSAs can reduce health care costs, but they are not true MSAs. In these examples, account balances do not accumulate for health expenses beyond 1 year, unused funds can be used without restriction, and the accounts do not receive favorable tax treatment that would put them on an equal footing with contributions for health insurance. How Do Medical Savings Accounts Work? If coupled with high-deductible health insurance policies, MSAs could provide a cost-saving alternative to first-dollar or low-deductible health insurance while providing protection for catastrophic expenses. Typical health insurance policies with first-dollar coverage or low deductibles tend to shield consumers from the full effect of health care prices. They provide little incentive for the consumer to shop for services on the basis of cost. Advocates of MSAs argue that increased cost-consciousness on the part of the consumer and substantial financial savings could be achieved by purchasing low-cost health insurance policies with high deductibles and establishing MSAs to fund the deductible and copayment amounts. Substantial savings in health insurance premiums may be achieved by switching from low- to high-deductible policies. For an individual person or family buying a nongroup policy, the savings might be as much as the difference in the premium amount [6]. Proponents argue that most employers could cut their health insurance premiums by one third with a

Seeking the Just Price: Constructing Relative Value Scales and Fee Schedules

2500 deductible, even without changes in health care consumption [6]. The savings in insurance premiums obtained from switching to a high-deductible plan could be used by employers to fund employee MSAs and might offset much, if not all, of the employees increased financial risk for the higher deductible amount. Employees could then take those tax-free funds from their personal accounts to pay for routine medical expenses. As soon as the deductible from the catastrophic policy is met, the insurance would cover expenses for any additional services [4]. Employers benefit from reduced health insurance premiums and can expect to curtail future costs. Employees benefit by accumulating unused funds for future health care expenses and by having greater discretion over health care spending done on their behalf. Example 1: An employer pays

Insurance Reform in a Voluntary System: Implications for the Sick, the Well, and Universal Health Care

4500 per year for each employee for standard health insurance coverage. Under an MSA plan, the employer would take

Will the 2012 Presidential Election Change Health Care

1500, purchase a policy with a