The table below is from one of my Quality and Resource Use Reports (QRUR). You can see the “ambulatory care-sensitive conditions include the conditions I mentioned on my last blog: bacterial pneumonia, urinary tract infection, dehydration, diabetes complications, chronic obstructive pulmonary disease (COPD)/asthma, and heart failure. I don’t know exactly what is contained in the “Chronic Conditions Composite” or the “Acute Conditions Composite.” Please message me if you know. Remember that the cost of care in these patients has been assigned to me because I see the patient more often than their other doctors. I have been incorrectly identified as the primary care physician, and worse, because I see patients so much sicker than the other doctors with my board certification, the per capita cost of my patients is out of alignment with the rest of my specialty.
There is ONE interesting piece of good news. I may spend more money per patient, but my patients get hospitalized less often than the patients of most family physicians, as you can see on the table of my data below.
The column labeled “your TIN’s Eligible Cases” are the patients with these conditions for whom I provided the plurality of services. I’d like to point out that I am only in clinic 2 days a week, but I still have 21 patients each with UTIs, dehydration, and pneumonia, even though I do not treat these conditions! Those are comorbid conditions in my wound care patients.
Next is the column labeled “Your TINs Performance Rate,” and all the values are“0.” That means none of the patients with these conditions got admitted to the hospital. The benchmark rate is the rate of hospitalization among family practice doctors. I did have 10 patients in the “all cause re-admission” category but since 20 patients are the threshold for a cost measures to matter, that was not a problem. In case you are wondering, most of my patients who get re-admitted have heart failure. What is frightening about the re-admission data is that I only practice 2 days a week and had 10 of these. If the threshold to be accountable is 20, what do you think would have happened if I practiced 5 days a week? I think I would have had more than 20 all-cause readmissions if I practiced full time. Like the hospital, I would be at risk of a claw-back of Medicare payments for failing to keep my patients out of the hospital.
As an aside ( I credit Helen Gelly with this observation), there is powerful data in support of hyperbaric oxygen therapy. It is to be found in the long term follow up of diabetic foot ulcer patients included in the Londahl prospective, randomized controlled trial of HBOT. All-cause death at 6 years among the Londahl subjects was significantly less in the HBOT group than the non-HBOT treated group. Also, they were less likely to exhibit a prolonged QTc interval, reducing their risk of arrhythmias and sudden death. The take home message is that we should be tracking the death rates of hyperbaric patients (something that is possible with a Qualified Clinical Data Registry, if only there was widespread support for data submission to a QCDR!). What if cancer survivors who get HBOT for late effects of radiation have an increase in life expectancy? I made that up but based on some biochemical and immune effects of HBOT, it is possible.
KEY POINT: We need to figure out if the patients we care for are less likely to have bad (expensive) health outcomes (e.g. hospitalization, death), particularly for one of the conditions on the CMS episode groups. Their better outcomes may not be outcomes we normally consider among our patients. For example, if an HBOT patient is less likely to have a heart attack down the road, it would be important and useful in the support of providing HBOT.