Incentives for Enhancing Stroke Care

Incentives for Enhancing Stroke Care Sandra M. Schneider, MD (Chair) Larry B. Goldstein, MD (Co-Chair) James G. Adams, MD Kenneth L. DeHart, M.D Michael D. Hill, MD Andrew M. Demchuk, MD Anthony Furlan, MD Michael T. Rapp, MD, JD Joseph P. Wood, M.D., J.D.

Principles & Caveats • Broad-based approach, but • No representation from • Third party payers • Hospital administrators • Primary care providers • Radiologists • Lessons from experience with acute thombolysis

Incentives Matrix Stakeholders Emergency Physicians Neurologists Health Systems Payers Domains Administrative Medical/ Scientific Financial Medicolegal

Emergency PhysiciansAdministrative • Over 90% of ED directors perceive their department is either at or over capacity • American Hospital Association- 62% of EDs are at or over capacity • Point prevalence study done on a typical spring evening found • 1.1 patients per treatment space • 4.2 patients per RN • 9.7 patients per physician • Nearly 70% of emergency department care is delivered in ‘off-hours’ • Stress in the system for delivery of optimal care

Emergency PhysicianstPA Experience • Medical/ scientific issues perceived as unresolved • Lack of consultative support for acute stroke treatment (radiological, neurological) is viewed as the most significant barrier • Lack of systems support • Medicolegal risk

Emergency PhysiciansIncentives • Improved consultative resources • Neurology/ radiology • Regional consultative practices • Telemedicine/ teleradiology • Poison Control Center model • Support development of primary stroke care centers & care systems • Care pathways/ protocols • Address staffing issues • Hospitals/ health care systems • Payers

NeurologyAdministrative • Limited numbers of neurologists who are concentrated in major metropolitan areas • Many neurologists sub-specialize and may not regularly care for stroke patients • No more than 50% of American neurologists have given IV tPA for acute stroke • General neurologists practice primarily in an outpatient setting • Need to be available to be called during a busy clinic, often off-site

NeurologyMedical/ Scientific/ Medicolegal: tPA Example • Debate about optimal patients for treatment • In one survey, less than one third (30%) of neurologists found the evidence for tPA efficacy “very convincing” • Many felt the drug was “too risky” • 62% were “very concerned” about ICH • Medicolegal concern Neurology 1998;50:1491-1494 Stroke 2001;32:861-865

NeurologyFinancial • Economics of clinical practice dictate a tightly scheduled day • Evaluation of a stroke patient can take several hours • Limited financial reimbursement is a disincentive to leaving a crowded office to provide emergency consultative services • Telephone consultation • Consultants are legally liable for advice given over the telephone • There is no financial reimbursement for telephone consultation • Neurologists frequently interpret radiographic studies such as CT scans to guide treatment • They are rarely financially reimbursed for these activities

NeurologyIncentives • Training of all new neurologists in stroke care • Paradigm shift • Continue to address medical and scientific concerns • Update current CPT coding with appropriate RVUs for acute stroke, including thrombolytic therapy • Reimbursement for telephone/telemedicine consultations and for interpretation of acute stroke imaging studies by neurologists • Clarify medicolegal liabilities related to acute stroke interventions, including telephone consultations

Health Systems • Support of health systems is critical • Because there may be different payers for acute and long-term care, even if an acute treatment is cost-effective from a societal standpoint, it may increase the costs to those providing the treatment that is not reimbursed (disincentive) • Currently no stroke CMS quality indicators • Little incentive to support stroke QI initiatives

Health SystemsIncentives • Studies show that having an organized system of care shortens LOS, decreases complications and can reduce costs • CMS will likely reintroduce stroke indicators • Programs to identify stroke centers are being discussed

Medicolegal • Malpractice • Violation of the accepted standard of care resulting in harm to a patient • In court, opinions about the standard of care are provided by one or more experts • The starting point for litigation is often a bad outcome (because the patient had a stroke)

MedicolegaltPA Example • Failure to administer • Had it been used, the outcome would have been the elimination of the patient’s neurological deficits • Hard to prove scientifically, but easy to establish in a court of law since it may merely require the opinion of a qualified witness • The administration was either not indicated or improperly administered • Hemorrhage or perhaps simply failure to be cured

Fertile Field for Malpractice Litigation • Uncertainty, lack of familiarity, lack of support • Popular press, magazines, and newspaper stories have sometimes overstated the therapeutic potential • Advertisements and websites of malpractice attorneys highlight the “alarmingly low” use of tPA for patients with acute stroke, “especially for African Americans.” 1 • “If you suspect that a loved one should have received tPA but did not, or that tPA was administered improperly, it may be important to contact an attorney.” 2 (1) www.cerebralpalsylegalhelp.com/cerebral/developments.html (2) http://www.injuryboard.com

Reducing Medicolegal Risk • Appropriate consultative support • Institutional evidence-based policies for the use of a treatment • Follow accepted guidelines or policy statements by professional organizations

Financial • Facilities reimbursed by governmental payers based on a Diagnosis Related Grouping (DRG) methodology • Largely reflects overhead costs calculated from “case data” with little recognition of the expense of new therapies • Commercial payers typically compensate on a “per diem” basis, with denied payment inconsistency • Physician payment based on CPT codes (E&M Codes) • CPT code for IV tPA for acute stroke (37195), the work RVU is 0 • Concurrent care may not be reimbursed (disincentive to team approach) • Financial support for stroke systems lacking

PayersIncentives to Improve Care • Recognition of the added value of supporting stroke care systems • Support medical leadership and system analysis (QI programs) • Reimbursement must reflect the increased costs to institutions providing new interventions • CPT-Code revision • Redefine existing codes (37195) • Develop specific new codes for acute stroke care • Advocate against restrictions based on concurrency of care • Support telephone consultation (codes exist, not paid) • Support telephone consultative centers (Poison Center Model) • Patient & professional groups need to advocate for change

The Bottom Line

Summary of Incentives -1 • Support the development and maintenance of stroke care systems • Provide acute stroke consultative support (especially neurological and radiological expertise) for ED physicians and non-specialist care providers through in-hospital protocols and systems approaches, including telemedicine consultation and teleradiology as appropriate

Summary of Incentives -2 • Develop a coordinated stroke reimbursement strategy involving patient advocates and professional organizations • Define medicolegal issues in order to reduce physician liability risk related to the provision of innovative acute stroke care • Support outcomes assessment programs to inform quality improvement efforts and dissemination of best practices

Summary of Incentives- 3 • Assure that appropriate education is conducted and that consensus is achieved as new therapies are introduced. Educational priorities include emergency caregivers, neurologists and nursing staff • Provide forums for constructive dialog among emergency physicians, neurologists and other key stroke care providers • Continue to refine and advance the level of stroke care through clinical research

Incentives Matrix Stakeholders Domains Stroke Patients

Incentives for Enhancing Stroke Care