incentives for enhancing stroke care

Incentives for Enhancing Stroke CareIncentives for Enhancing Stroke Care

Sandra M. Schneider, MD (Chair)Sandra M. Schneider, MD (Chair)Larry B. Goldstein, MD (Co-Chair)Larry B. Goldstein, MD (Co-Chair)

James G. Adams, MDJames G. Adams, MDKenneth L. DeHart, M.DKenneth L. DeHart, M.D

Michael D. Hill, MDMichael D. Hill, MDAndrew M. Demchuk, MDAndrew M. Demchuk, MD

Anthony Furlan, MDAnthony Furlan, MDMichael T. Rapp, MD, JDMichael T. Rapp, MD, JD

Joseph P. Wood, M.D., J.D.Joseph P. Wood, M.D., J.D.

Principles & CaveatsPrinciples & Caveats

Broad-based approach, butBroad-based approach, but No representation fromNo representation from

– Third party payersThird party payers– Hospital administrators Hospital administrators – Primary care providersPrimary care providers– RadiologistsRadiologists

Lessons from experience with acute thombolysisLessons from experience with acute thombolysis

Incentives MatrixIncentives Matrix

MedicolegalMedicolegal

FinancialFinancial

Medical/Medical/ScientificScientific

AdministrativeAdministrative

PayersPayersHealthHealthSystemsSystems

NeurologistsNeurologistsEmergency Emergency PhysiciansPhysicians

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StakeholdersStakeholders

Emergency PhysiciansEmergency PhysiciansAdministrativeAdministrative

Over 90% of ED directors perceive their department is Over 90% of ED directors perceive their department is either at or over capacityeither at or over capacity

American Hospital Association- 62% of EDs are at or American Hospital Association- 62% of EDs are at or over capacityover capacity

Point prevalence study done on a typical spring Point prevalence study done on a typical spring evening foundevening found– 1.1 patients per treatment space1.1 patients per treatment space– 4.2 patients per RN4.2 patients per RN– 9.7 patients per physician9.7 patients per physician

Nearly 70% of emergency department care is Nearly 70% of emergency department care is delivered in ‘off-hours’delivered in ‘off-hours’

Stress in the system for delivery of optimal careStress in the system for delivery of optimal care

Emergency PhysiciansEmergency PhysicianstPA ExperiencetPA Experience

Medical/ scientific issues perceived as unresolvedMedical/ scientific issues perceived as unresolved Lack of consultative support for acute stroke Lack of consultative support for acute stroke

treatment (radiological, neurological) is viewed as treatment (radiological, neurological) is viewed as thethe most significant barrier most significant barrier

Lack of systems supportLack of systems support Medicolegal riskMedicolegal risk

Emergency PhysiciansEmergency PhysiciansIncentivesIncentives

Improved consultative resourcesImproved consultative resources– Neurology/ radiologyNeurology/ radiology– Regional consultative practicesRegional consultative practices

• Telemedicine/ teleradiologyTelemedicine/ teleradiology– Poison Control Center modelPoison Control Center model

Support development of primary stroke care Support development of primary stroke care centers & care systemscenters & care systems– Care pathways/ protocolsCare pathways/ protocols

Address staffing issuesAddress staffing issues– Hospitals/ health care systemsHospitals/ health care systems– PayersPayers



FinancialFinancial





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NeurologyNeurologyAdministrativeAdministrative

Limited numbers of neurologists who are Limited numbers of neurologists who are concentrated in major metropolitan areasconcentrated in major metropolitan areas

Many neurologists sub-specialize and may not Many neurologists sub-specialize and may not regularly care for stroke patientsregularly care for stroke patients– No more than 50% of American neurologists have given IV tPA for No more than 50% of American neurologists have given IV tPA for

acute strokeacute stroke General neurologists practice primarily in an General neurologists practice primarily in an

outpatient settingoutpatient setting– Need to be available to be called during a busy clinic, often off-siteNeed to be available to be called during a busy clinic, often off-site

NeurologyNeurologyMedical/ Scientific/ Medicolegal: tPA ExampleMedical/ Scientific/ Medicolegal: tPA Example

Debate about optimal patients for treatmentDebate about optimal patients for treatment In one survey, less than one third (30%) of In one survey, less than one third (30%) of

neurologists found the evidence for tPA efficacy neurologists found the evidence for tPA efficacy “very convincing”“very convincing”

Many felt the drug was “too risky”Many felt the drug was “too risky” 62% were “very concerned” about ICH62% were “very concerned” about ICH Medicolegal concernMedicolegal concern

NeurologyNeurology 1998;50:1491-1494 1998;50:1491-1494StrokeStroke 2001;32:861-865 2001;32:861-865

NeurologyNeurologyFinancialFinancial

Economics of clinical practice dictate a tightly Economics of clinical practice dictate a tightly scheduled dayscheduled day

Evaluation of a stroke patient can take several hoursEvaluation of a stroke patient can take several hours Limited financial reimbursement is a disincentive to Limited financial reimbursement is a disincentive to

leaving a crowded office to provide emergency leaving a crowded office to provide emergency consultative servicesconsultative services

Telephone consultationTelephone consultation– Consultants are legally liable for advice given over the telephoneConsultants are legally liable for advice given over the telephone– There is no financial reimbursement for telephone consultationThere is no financial reimbursement for telephone consultation

Neurologists frequently interpret radiographic studies Neurologists frequently interpret radiographic studies such as CT scans to guide treatmentsuch as CT scans to guide treatment– They are rarely financially reimbursed for these activitiesThey are rarely financially reimbursed for these activities

NeurologyNeurologyIncentivesIncentives

Training of Training of allall new neurologists in stroke care new neurologists in stroke care– Paradigm shiftParadigm shift

Continue to address medical and scientific concernsContinue to address medical and scientific concerns Update current CPT coding with appropriate RVUs for Update current CPT coding with appropriate RVUs for

acute stroke, including thrombolytic therapyacute stroke, including thrombolytic therapy Reimbursement for telephone/telemedicine Reimbursement for telephone/telemedicine

consultations and for interpretation of acute stroke consultations and for interpretation of acute stroke imaging studies by neurologistsimaging studies by neurologists

Clarify medicolegal liabilities related to acute stroke Clarify medicolegal liabilities related to acute stroke interventions, including telephone consultationsinterventions, including telephone consultations



FinancialFinancial





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Health SystemsHealth Systems

Support of health systems is criticalSupport of health systems is critical Because there may be different payers for acute Because there may be different payers for acute

and long-term care, even if an acute treatment is and long-term care, even if an acute treatment is cost-effective from a societal standpoint, it may cost-effective from a societal standpoint, it may increase the costs to those providing the increase the costs to those providing the treatment that is not reimbursed (disincentive)treatment that is not reimbursed (disincentive)

Currently no stroke CMS quality indicatorsCurrently no stroke CMS quality indicators Little incentive to support stroke QI initiativesLittle incentive to support stroke QI initiatives

Health SystemsHealth SystemsIncentivesIncentives

Studies show that having an organized system of Studies show that having an organized system of care shortens LOS, decreases complications and care shortens LOS, decreases complications and can reduce costscan reduce costs

CMS will likely reintroduce stroke indicatorsCMS will likely reintroduce stroke indicators Programs to identify stroke centers are being Programs to identify stroke centers are being

discusseddiscussed



FinancialFinancial





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MalpracticeMalpractice– Violation of the accepted standard of care resulting in harm to a Violation of the accepted standard of care resulting in harm to a

patientpatient In court, opinions about the standard of care are In court, opinions about the standard of care are

provided by one or more expertsprovided by one or more experts The starting point for litigation is often a bad The starting point for litigation is often a bad

outcome (because the patient had a stroke)outcome (because the patient had a stroke)

MedicolegalMedicolegaltPA ExampletPA Example

Failure to administerFailure to administer– Had it been used, the outcome would have been the Had it been used, the outcome would have been the

elimination of the patient’s neurological deficitselimination of the patient’s neurological deficits– Hard to prove scientifically, but easy to establish in a court of Hard to prove scientifically, but easy to establish in a court of

law since it may merely require the opinion of a qualified law since it may merely require the opinion of a qualified witnesswitness

The administration was either not indicated or The administration was either not indicated or improperly administeredimproperly administered– Hemorrhage or perhaps simply failure to be curedHemorrhage or perhaps simply failure to be cured

Fertile Field for Malpractice LitigationFertile Field for Malpractice Litigation

Uncertainty, lack of familiarity, lack of supportUncertainty, lack of familiarity, lack of support Popular press, magazines, and newspaper stories Popular press, magazines, and newspaper stories

have sometimes overstated the therapeutic potentialhave sometimes overstated the therapeutic potential Advertisements and websites of malpractice attorneys Advertisements and websites of malpractice attorneys

highlight the “alarmingly low” use of tPA for patients highlight the “alarmingly low” use of tPA for patients with acute stroke, “especially for African Americans.” with acute stroke, “especially for African Americans.” 11

““If you suspect that a loved one should have received If you suspect that a loved one should have received tPA but did not, or that tPA was administered tPA but did not, or that tPA was administered improperly, it may be important to contact an improperly, it may be important to contact an attorney.” attorney.” 22

(1) (1) www.cerebralpalsylegalhelp.com/cerebral/developments.htmlwww.cerebralpalsylegalhelp.com/cerebral/developments.html(2) (2) http://www.injuryboard.comhttp://www.injuryboard.com

Reducing Medicolegal RiskReducing Medicolegal Risk

Appropriate consultative supportAppropriate consultative support Institutional evidence-based policies for the use of a Institutional evidence-based policies for the use of a

treatmenttreatment Follow accepted guidelines or policy statements by Follow accepted guidelines or policy statements by

professional organizationsprofessional organizations



FinancialFinancial





DDoommaaiinnss


FinancialFinancial

Facilities reimbursed by governmental payers based Facilities reimbursed by governmental payers based on a on a Diagnosis Related GroupingDiagnosis Related Grouping (DRG) methodology (DRG) methodology– Largely reflects overhead costs calculated from “case data” with little Largely reflects overhead costs calculated from “case data” with little

recognition of the expense of new therapiesrecognition of the expense of new therapies Commercial payers typically compensate on a “Commercial payers typically compensate on a “per per

diemdiem” basis, with denied payment inconsistency ” basis, with denied payment inconsistency Physician payment based on CPT codes (E&M Codes)Physician payment based on CPT codes (E&M Codes)

– CPT code for IV tPA for acute stroke (37195), the work RVU is 0CPT code for IV tPA for acute stroke (37195), the work RVU is 0– Concurrent care may not be reimbursed (disincentive to team Concurrent care may not be reimbursed (disincentive to team

approach)approach) Financial support for stroke systems lackingFinancial support for stroke systems lacking

PayersPayersIncentives to Improve CareIncentives to Improve Care

Recognition of the added value of supporting stroke Recognition of the added value of supporting stroke care systemscare systems– Support medical leadership and system analysis (QI programs)Support medical leadership and system analysis (QI programs)

Reimbursement must reflect the increased costs to Reimbursement must reflect the increased costs to institutions providing new interventionsinstitutions providing new interventions

CPT-Code revisionCPT-Code revision– Redefine existing codes (37195)Redefine existing codes (37195)– Develop specific new codes for acute stroke careDevelop specific new codes for acute stroke care– Advocate against restrictions based on concurrency of careAdvocate against restrictions based on concurrency of care– Support telephone consultation (codes exist, not paid)Support telephone consultation (codes exist, not paid)

Support telephone consultative centers (Poison Support telephone consultative centers (Poison Center Model)Center Model)

Patient & professional groups need to advocate for Patient & professional groups need to advocate for changechange

The Bottom LineThe Bottom Line

Summary of Incentives -1Summary of Incentives -1

Support the development and maintenance of stroke Support the development and maintenance of stroke care systemscare systems

Provide acute stroke consultative support (especially Provide acute stroke consultative support (especially neurological and radiological expertise) for ED neurological and radiological expertise) for ED physicians and non-specialist care providers through physicians and non-specialist care providers through in-hospital protocols and systems approaches, in-hospital protocols and systems approaches, including telemedicine consultation and teleradiology including telemedicine consultation and teleradiology as appropriateas appropriate

Summary of Incentives -2Summary of Incentives -2

Develop a coordinated stroke reimbursement Develop a coordinated stroke reimbursement strategy involving patient advocates and professional strategy involving patient advocates and professional organizationsorganizations

Define medicolegal issues in order to reduce Define medicolegal issues in order to reduce physician liability risk related to the provision of physician liability risk related to the provision of innovative acute stroke careinnovative acute stroke care

Support outcomes assessment programs to inform Support outcomes assessment programs to inform quality improvement efforts and dissemination of quality improvement efforts and dissemination of best practicesbest practices

Summary of Incentives- 3Summary of Incentives- 3

Assure that appropriate education is conducted and Assure that appropriate education is conducted and that consensus is achieved as new therapies are that consensus is achieved as new therapies are introduced. Educational priorities include emergency introduced. Educational priorities include emergency caregivers, neurologists and nursing staffcaregivers, neurologists and nursing staff

Provide forums for constructive dialog among Provide forums for constructive dialog among emergency physicians, neurologists and other key emergency physicians, neurologists and other key stroke care providersstroke care providers

Continue to refine and advance the level of stroke Continue to refine and advance the level of stroke care through clinical researchcare through clinical research


Emergency Emergency PhysiciansPhysicians

NeurologistsNeurologists HealthHealthSystemsSystems

PayersPayers



FinancialFinancial


DDoommaaiinnss


incentives for enhancing stroke care

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stroke patientsno

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