Annual Medical Services Review Report - Kansas

Kansas Foundation for Medical Care, Inc.

Time Frame: From August 2001 - May 2002

If you would like to receive this annual report via email as a Portable Document Format (PDF) attachment, please send email to Relations@kfmc.org. If you would prefer to receive a printed brochure by mail, please email your name and address to Relations@kfmc.org.

Introduction

The Kansas Foundation for Medical Care, Inc., [KFMC] is designated by the Centers for Medicare & Medicaid Services [CMS] as the Quality Improvement Organization [QIO] for Kansas. KFMC receives CMS funding to work with Kansas health providers to improve the safety and health of Kansans enrolled in Medicare through quality improvement initiatives and other services such as medical case review and consumer education. The purposes are to:

• Improve the quality of care for beneficiaries by ensuring that care meets professionally recognized standards of healthcare,
• Protect beneficiaries by expeditiously addressing individual cases such as consumer complaints, and
• Protect the integrity of the Medicare Trust Fund and the taxpayer dollars that fund it by ensuring that Medicare pays only for services and items that are reasonable and medically necessary and that are provided in an appropriate setting.

This brochure summarizes the work KFMC conducted under the CMS contract between August 2001 and May 2002.

Consumer Education

Outreach

KFMC educates beneficiaries about their rights in the Medicare program through a variety of efforts such as trade shows, senior health fairs, and outreach presentations to community groups. KFMC impacted nearly 4,000 beneficiaries through these outreach efforts during this reporting period. KFMC also helps beneficiaries understand the benefits of receiving preventive services such as mammograms, influenza and pneumonia immunizations, and ongoing tests for diabetes. KFMC's quarterly newsletter "To Your Health," which boasts 20,000 subscribers, is another tool used to educate beneficiaries.

Toll-free Hotline

KFMC fielded about 550 calls on its toll-free help line [800-432-0407] from beneficiaries, spouses and relatives, Congressional offices, health providers, senior organizations or other callers between August 2001 and May 2002. All were reviewed internally or referred to other appropriate agencies.

Partnerships

KFMC works closely with Congressional offices and has established partnerships with several beneficiary advocacy organizations to better serve Kansans enrolled in Medicare. KFMC relies on a 20-member panel of consumers and advocacy groups who volunteer to help with outreach efforts.

Medical Case Review

Protection

KFMC conducts individual medical case review to determine if inappropriate or unnecessary care has been provided, whether services were rendered in an inappropriate setting, or whether services met professionally recognized standards of care. KFMC reviews all written beneficiary complaints related to quality of care and Hospital Issued Notices of Noncoverage [HINNs], Notices of Discharge and Medicare Appeal Rights, and violations of the Emergency Medical Treatment and Labor Act [EMTLA]. KFMC also reviews requests for hospital payment and utilization review. KFMC selected 1,066 cases for review during this reporting period.

Quality Improvement

KFMC conducts quality improvement projects on seven key topics: heart failure, acute myocardial infarction [AMI], stroke, pneumonia, adult immunizations, diabetes, and mammography. During these projects, KFMC provides expert consultation, technical assistance, and education materials to help providers achieve improvement goals. Benefits of participation include data management tools such as data analysis and feedback on patterns of care at the state, peer group, and facility-specific level, quality improvement interventions and expertise, free education for providers, materials for patients, and a forum for collaboration among facility participants to share successes and lessons learned. KFMC co-sponsored the American Heart Association's Heart Ball in February 2002 in an effort to promote quality improvement activities.

Inpatient Projects

Participants

During this reporting period, KFMC recruited 77 Kansas hospitals to participate in the inpatient healthcare quality improvement project. Hospitals selected designated quality indicators to target for improvement. Throughout this project, KFMC provided educational programs and patient education materials, resources and tools, technical assistance, data support, and other assistance to help hospitals implement changes to improve quality outcome measures. An educational course also was offered on "Quality Performance Variation" for CME and CNE credit.

Collaborator Meeting

In a face-to-face meeting with participating hospitals, KFMC shared results of performance measures, contrasting the time periods of statewide baseline, two interim measurements, and the statewide remeasurement. Hospitals showed marked improvement in beta blockers for AMI patients, timeliness of emergent angioplasty, improvements in stroke management, better antibiotic selections for pneumonia patients, and improvements in screening for immunizations. Three Kansas hospitals shared intervention strategies, successes, barriers, and lessons learned with other hospitals in attendance in an effort to enhance learning and improvement.

Awards

KFMC presented Quality Awards for Excellence to the top small-, medium-, and large-sized hospitals for achievement during quality improvement activities between October 2000 and May 2001. Awards for the top participants in quality improvement activities during the current reporting period are expected to be determined before August 1, 2002.

Critical Access Hospitals [CAHs]

KFMC completed a quality improvement project for Critical Access Hospitals [CAHs] designed to increase the number of hospitalized patients screened for or given influenza and pneumonia immunizations. Eighteen CAHs participated. Documentation of immunization status improved for both influenza [from 17% to 62%] and pneumonia [from 36% to 51%]. While the hospitals fared well in screening, KFMC identified opportunities for improvement in administration of immunizations before discharge. Medicare+Choice Organizations [MCOs]

CAHPS & HOS Analyses

KFMC provided clinical and biostatistical expertise to Kansas' Medicare+Choice Organizations [MCOs] regarding the design and conduct of the MCO's quality improvement projects. KFMC also met with and provided technical assistance to the MCOs. Technical assistance consisted of information dissemination, assistance in developing data collection tools, data abstraction, and provision of intervention materials. [When this reporting period began, Kansas had two MCOs, but one has since withdrawn from the Medicare business.] KFMC analyzed the 2000 Medicare Managed Care Consumer Assessment of Health Plans Study [CAHPS] to compare key characteristics of the Kansas-based MCO with the overall characteristics of all Kansas beneficiaries enrolled in an HMO. The Kansas MCO compared favorably with other health plans in all categories except health plan customer service, where 60% of respondents said the customer service they received was "not a problem," compared to 68% statewide. KFMC also analyzed the 2000 Medicare Health Outcomes Survey [HOS] and found significant statistical differences in the mental and physical health of survey participants when compared by age, gender, and race. The analyses were then submitted to the Kansas MCOs for their internal use.

Abstraction

KFMC abstracted 172 cases at nine offices between December 2001 and January 2002 for a heart failure QAPI project for an MCO that has now discontinued its Senior Care Program.

Preventive Care Initiative

Academic Detailing

Through the Preventive Care Initiative, KFMC promoted adult immunizations, mammography, and diabetes care through academic detailing visits. KFMC made 319 physician office detailing visits in 134 Kansas communities between January 2000 and December 2001. [See Fig. 2] During these visits, KFMC staff reviewed baseline rates for Hemoglobin A1c measurements, lipid profiles, and dilated eye exams for diabetes care, as well as baseline rates for mammography and influenza and pneumonia immunizations. KFMC then identified the need for improvement in each of these indicators.

Interventions & Follow-up

Using practice-specific information generated from Medicare claims data, KFMC compared physician offices with state averages and benchmark practices to help providers determine areas of focus for quality improvement. KFMC provided intervention materials such as standing orders, flowsheets, office reminder system tools, and patient education materials to help providers implement system changes to enhance care. Providers who were interested in implementing office system tools were offered on-site Continuing Nursing Education [CNE] for all nursing and allied health staff. This CNE included development of an office action plan. KFMC contacted participating physician offices two to four weeks after the site visit to assess whether office system changes had been implemented. KFMC also provided further consultation on the use of interventions and re-tasking issues and identified plans for the office to make improvements in preventive care. Subsequent follow-up contacts to ensure the adoption of office system changes and re-tasking in physician offices were conducted by KFMC staff in late 2001 and early 2002.

Resources

KFMC was available to collaborators for ongoing technical support as needed. This allowed practices to gain access to new ideas and support. KFMC also made continuing nursing and medical education available through the Internet. KFMC worked with the University of Kansas Medical Center to develop two Internet sites devoted to preventive care education for nurses and physicians. One site provided education on diabetes care, while the other provided information on general preventive care. Features included downloadable flowsheets and standing orders, hotlinks to professional organizations, hotlinked references, and quizzes. Nurses and physicians received an online certificate for one credit hour of continuing education.

Promotion

KFMC promoted the initiative through beneficiary outreach activities, exhibit booths, and professional meeting presentations across the state. KFMC also sponsored major events such as the Race Against Breast Cancer in Topeka and the American Diabetes Association Diabetes Walk.

Tri-County African American Diabetes [TriAAD] Project

Reducing Disparities

KFMC designed the Tri-County African American Diabetes [TriAAD] project to reduce disparity in annual hemoglobin A1c testing between African American and white Medicare beneficiaries with diabetes in the Kansas counties of Shawnee, Sedgwick, and Wyandotte. These counties contain 75% of the Kansas Medicare African American diabetic population.

Interventions

Interventions targeted primarily providers and secondarily beneficiaries. Provider-focused academic detailing was designed to enhance awareness of disparity and promote the use of reminders to order HbA1c testing, while beneficiary-focused interventions encouraged self-monitoring of their diabetes and education materials.

Round Table Meeting

In February 2002, KFMC organized a round table meeting of providers, community-based groups, and special interest groups to discuss initiatives, perspectives, and knowledge of diabetes treatment for African Americans in Wyandotte County. KFMC acquired new contacts, improved relationships with partners, and expanded opportunities for connecting with target populations.

Analysis

Monitoring of the TriAAD project included periods of baseline, interim, and remeasurement analyses. While local Medicare carrier data were used for monitoring, CMS diabetes data are being used to assess impact of the project. Final analysis for this project is projected for the fall of 2002.

Heart Failure Practice Improvement Effort [HF-PIE]

Feasibility Study

The Heart Failure Practice Improvement Effort [HF-PIE] was a collaborative pilot project between eight QIOs representing 12 states. The purpose was to examine the feasibility of conducting a heart failure project in the outpatient setting. During the final in-person meeting in April 2002, the participating QIOs, the Heart Failure QIO Support Center, and CMS staff determined that it was feasible to recruit collaborators, schedule and make visits for abstraction and education, identify patients for inclusion, collect data from charts, locate information in patient charts, and provide feedback to collaborators.

Recruitment & Measurement

KFMC recruited 17 outpatient practices including Family Practice, Internal Medicine, and Cardiology practices. Only one physician office did not complete the project. KFMC staff abstracted data from charts of patients with heart failure at each practice. Baseline, interim, and remeasurement data collection was completed and feedback given to providers. Remeasurement data abstraction was completed between October and November 2001, and 382 charts that met the requirements for remeasurement were included in that sample.

Interventions

Interventions to improve heart failure care consisted primarily of practice-specific peer comparison feedback. Project collaborators also were provided with patient education materials, flowcharts, and treatment algorithms.

Results

At baseline, 80% of heart failure patients had a Left Ventricular Function [LVF] assessment documented compared to 81% at remeasurement. At baseline, 91% of those with a LVF assessment less than 40% were on an Angiotension Converting Enzyme Inhibitor [ACEI] or had a documented reason for not being prescribed an ACEI. At remeasurement the rate was 80%, not a statistically significant decline.

Payment Error Prevention Program

Module 8

Five hospitals participated in KFMC's eighth PEPP project, which ended in December 2001. The overall compliance remeasurement rate for medical necessity significantly improved from 71.4% at baseline to 81.5%. The overall remeasurement rate for DRG validation rose slightly from 89% at baseline to 90.5% at the end of the onsite work.

Module 9

Six hospitals participated in KFMC's ninth PEPP project - five of which had participated in a previous PEPP project. KFMC visited the Module 9 hospitals in 2002. From the February baseline to the May remeasurement, the average medical necessity compliance rate modestly increased from 83.3% to 84.2%. The overall remeasurement rate for DRG validation increased from 90.8% to 93.3%.

Compliance Audits

PEPP provides compliance plan audits for Kansas hospitals. The service is primarily designed for small Peer Group 1 hospitals and is offered on a voluntary basis. Audits are performed in two steps. The first is the "desk audit" in which PEPP staff compare volunteer hospitals' compliance plans and supporting work papers to guidelines. Then PEPP provides the hospitals with confidential reports with recommendations. In the second step, PEPP staff conduct "field audits" six months after desk audits have been completed. Staff conduct random interviews with Corporate Compliance Committee members, department heads, and staff to determine if the facility actually follows its Corporate Compliance plan and functions under its Code of Conduct as written. PEPP staff then provide a confidential report to the facilities. KFMC completed five desk audits and six field audits during this reporting session.

IRR Special Study

PEPP completed a special project, "Establishing Inter-Rater Reliability Rates for the Payment Error Prevention Program Evaluation," in the third quarter of 2001. KFMC partnered with seven other QIOs to provide non-physician and first-level physician review results on a uniform case bank, comprised of 15 records from each participating state [120 total cases] as part of a CMS special study. Substantial differences occurred between states at the physician and non-physician review level for DRG validation, admission necessity, and quality of care.

Program Evaluation & Future Activities

CMS surveillance payment error rates were released during this reporting period. Kansas' rate [2.36%] compared favorably to the national rate [4.41%]. However, based on these rates, KFMC was unable to show quantifiable program savings. KFMC will rely on federally provided remeasurements and will aggressively analyze them. Projects will be proposed to address payment or utilization issues.

Continuing Professional Education

Continuing education is a key ingredient in the success of the KFMC quality improvement efforts. KFMC is accredited to conduct Continuing Medical and Nursing Education. Allied health continuing education recognition also is offered for appropriate programs. Continuing education programs and activities are an integral part of KFMC's quality improvement efforts and continue to be viewed as tremendous benefits for collaborators. Current scientific data, knowledge, and care standards serve as the base for educational content. Educational programs provide a forum that promotes open communication, learning, and professional growth to improve the quality and effectiveness of healthcare.