Dear Person with MS,
The American Academy of Neurology (AAN) put together a Multiple Sclerosis Work Group to develop a list of quality measures specific to MS. These quality measures (or measures based on them) will most likely be used by insurance companies (including Medicare) to decide whether your neurologist is doing a good job or not. Failure to meet these quality measures will mean reduced reimbursement for services (and even having your doctor removed from the insurance rolls).
You have a unique opportunity (until Sept. 10, 2014) to comment on these draft quality measures, and to have your voice heard. I have included the comments that I personally sent to the members of the MS Work Group. As you will see, while the intention of improving quality is always laudable, in practice this draft quality measurement set falls short of what we need to improve the care of people with MS.
- To read the AAN MS Work Group's draft quality measures, please download the file here.
- To send in you own comments to the AAN, please visit this site (after filling in your information, scroll to the bottom of the page).
- If you are having access issues that you want to share (anonymously or not) with the community of medical professionals dedicated to those living with MS, then please visit the Medical Partnership 4 MS portal here.
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American
Academy of Neurology
201
Chicago Avenue
Minneapolis,
MN 55415
Phone:
(612) 928-6100
Fax:
612-454-2744
Dear Multiple Sclerosis
Work Group:
Thank you for inviting
public comment on the draft quality measurement set. Improving quality is
always an important ideal, but it is often more difficult to measure quality in
medical care.
From a practical
perspective, these quality measures will be used by third party payors to
decide reimbursement rates for individual physicians, but it is unclear how
successful completion of these quality measures will apply to two or more
physicians who are co-managing patients with multiple sclerosis (MS). Can one
physician (e.g. a general neurologist) fulfill her quality measures by simply
pointing to the requested assessments performed by the MS sub-specialist? There
are too few neurologist in general, and there are even fewer neurologist who
focus on MS – might these burdensome and time-consuming draft quality measures
further incentivize physicians to choose not to care for patients with MS
I share the concerns
raised by many others regarding these draft quality measures – they do little
to improve patient care, and they endanger patient access to care due to their
burdensome time requirements that will further push physicians away from
wanting to care for people with MS.
Please find my comments
below separated by section (and page number), including
typographical/grammatical corrections:
Topic Importance
p. 5 – “This high cost burden review did not include
newer, more costly therapies.”
It
would be more accurate to state that the review did not include the newer, more
costly price of therapies. Much of the price increases have nothing to do with
the newer medications alone, but with the price of older medications, as well.
Opportunities for
Improvement
p.
5 – “Treatment
use remains uneven, and treatment of MS is much debated due to the fact
available treatments are expensive and do not always meet standards for
cost-effectiveness.”
It
is not accurate to state that, “treatment of MS is much debated.” While the
treatments are expensive, there is little debate among neurologists that MS
patients deserve to be treated (despite the expense).
Desired Outcomes
p.
7 – “Decrease
rates of comorbidities (i.e, HTN, Diabetes, Smoking Obesity)”
There
is a missing comma between “Smoking” and “Obesity.” There is a missing period
after i.e
MULTIPLE
SCLEROSIS MEASUREMENT SET
1.
Multiple Sclerosis (MS) Diagnosis
p.
10 – “Percentage of patients with MS who met the Revised McDonald Criteria
(2011).“
At various points in this
measure description, the year 2011 is used, while at other points, the year
2010 is used. This can lead to confusion – since the 2010 Revised McDonald
criteria were published in 2011.
2. MRI of
Brain with Gadolinium for Comparison
p. 13 – “A brain MRI with
gadolinium …for the following of MS patients to assess subclinical disease
activity should be CONSIDERED every 1 to 2 years.“
Since MRIs should only be
“considered,” doesn’t this measure have the potential risk of encouraging
excessive MRI ordering on every MS patient (not excluded in the denominator)?
The flipside of this is
that insurers may use the “24 months” threshold to deny authorization for MRIs
at 12 months.
3. Current
MS Disability Scale Score
p. 16 – “Percentage of patients
with MS who have a MS disability scale score* documented in the medical record
in the past 12 months.”
Throughout
this measure description, “a MS,” instead of “an MS” is used.
p. 16 – “MS disability scale
score is defined as the score obtained from administering either the Kurtzke
Expanded Disability Status Scale (EDSS) or European Database on MS Grading System (EDMUS-GS), Functional Independence
Measure (FIM), Guy’s Neurological Disability Scale (GNDS), Neurological Rating
Scale from the Scripps Clinic, or having the patient complete the Patient Determined
Disease Steps (PDDS).”
Is there a reason that the
Multiple Sclerosis Functional Composite (MSFC) was excluded?
Are clinicians expected to
perform the full EDSS, including a 500-meter walk? If a clinician performs the
EDSS without the 500-meter walk are these in compliance with this draft quality
measure.
p.
16 – “Not all patients in clinical practice have an annual EDSS or other
validate MS scale measurement.“
There appears to be a
typographical error – “validated” should replace “validate.”
p. 16 – “Clinicians cannot detect
disability progression unless there is regular assessment.“
Formal
disability scales are not the only way t detect disability progression.
Neurological assessments (including history and examination) can also detect
progression of disability.
4. Fall
Risk Screening (Paired Measure)
p.
19 – “Percentage of patients with MS who were screened for fall risk in past 12
months.“
Asking
MS patients whether they have fallen in the past 12 months is a reasonable part
of standard neurologic history taking.
5. Fall
Risk Follow-Up (Paired Measure)
p.
22 – “Percentage of patients with MS with a positive fall risk screen and who
have a follow-up plan documented in the medical record on the date the provider
became aware of positive screen.“
While
having (and documenting) a falls follow-up plan is important, it seems
unreasonable to expect it “on the fate the provider became aware of positive
screen.” The MS Work Group may want to consider allowing some time delay.
6. Pain
Screening
p.
25 – “Percentage of patients with MS who were screened for pain at every
visit.“
While
screening for pain (and even more importantly, actually addressing it) is very
important, there is a need to clarify the term “every visit.” Sometimes
patients come in to a physician’s office for intramuscular injections – would
this be considered a “visit?”
7. Bladder
Infections
p.
28 – “Percentage of patients with MS who have had a bladder infection in past
12 months.“
While
preventing urinary tract infections is an important goal, the measure, as
worded, incentivizes physicians to see patients with milder MS as they may have
less bladder infections. Additionally, physicians may be hesitant to test for
bladder infections, since finding an infection could contribute to a lower quality score.
This
draft measure, like many others, misses the mark and does not accurately
reflect the “supporting guideline & other references” that highlight
“ask”ing and “assess”ing. A quality physician is one who assesses her patients,
not one who has tries to attract patients with milder MS with less bladder
infections.
8. Exercise and
Appropriate Physical Activity Counseling Measure
p.
31 – “Encourage people with MS to exercise and advise them that exercise does
not have any harmful effects on their MS.”
This
draft measure is appropriate since it focuses on physicians educating their
patients, but it may be confusing to state that “exercise does not have any harmful effects” [emphasis added].
Appropriate exercise may not have harmful effects, but inappropriate exercise
for the individual patient may have harmful effects (related to MS and
not).
9. Fatigue Outcome
Measure
p.
34 – “The desired outcome is to reduce or eliminate fatigue in MS patients. The
measure will provide an incentive for providers to identify and manage fatigue
in MS patients.“
This
draft quality measure is counterproductive since it perversely incentivizes
physicians to see patients with milder MS and avoid patients with more severe
MS. While the draft measure provides an incentive to manage fatigue, third
party payors routinely deny coverage for medications used to treat MS fatigue;
this places patients and their physicians in a precarious situation. If a
physician selects a medication for a patient’s fatigue, but that medication is
not covered by the third party payor, will the physician’s quality scores still
suffer?
This
draft measure makes the assumption that physicians aren’t already attempting to
“identify and manage fatigue,” while at the same time giving third party payors
further reasons to deny coverage for fatigue medications – theoretically, a
third party payor could deny coverage of the fatigue medications to save the
cost of pharmaceuticals while also causing the physician’s quality score to
drop, and thereby saving money by cutting the physician’s reimbursement.
10. Cognitive Impairment
Screening Measure
p. 37 – “Percentage of patients 18 years and older with MS
who were screened or tested for cognitive impairment in the past 12 months.“
While assessing cognitive function is an important
part of treating people with MS, there are many patients who do not require a yearly
cognitive test. This draft measure would encourage over testing, and further
reduce the amount of time that patients spend with their physicians discussing
their unique situation. As stated in the draft document, “the full BICAMS takes
approximately 15 minutes to administer,” this means that every MS patient would
need to spend one office visit a year in screening that may not benefit her or
be medically reasonable nor necessary.
p. 37 – “Although numerous brief cognitive assessments
could be used, recommended is the Brief International Assessment of Cognition
for MS (BICAMS) …”
It is not appropriate for this draft quality measure
document to recommend one screening tool over another (it is outside the scope
of the draft document).
p. 37 – “An optional, though not preferred, approach is to
screen with the SDMT2 only,
which requires a single 90 second trial.“
The wording of the draft document may inadvertently
be creating a legal standard for practice, and choosing the SDMT (when
appropriate) or other non-preferred testing may place neurologists at risk.
p. 37 – “Referral for formal neuropsychological testing is
also be appropriate.“
This
sentence is grammatically incorrect; consider removing the word “be.”
p.
38 – “Once identified, such deficits could be treated (or patients referred to
appropriate resources) and thereby improve individuals quality of life.“
This
sentence makes the assumption that well validated treatment exists to treat
cognitive dysfunction, and that by simply quantifying cognitive dysfunction
patients will have improved cognition and even quality of life. Some patients
may not improve cognitively, and simply quantifying cognitive decline may not
improve their quality of life.
p.
38 – “Clinicians cannot detect cognitive impairment unless there is regular
assessment.“
Screening
tools are not the only way for clinicians to detect cognitive dysfunction.
11. Clinical Depression
Screening Measure
p.
41 – “Percentage of patients aged 12 years and older with MS who were screened
for clinical depression using an age appropriate standardized depression
screening tool at least once in past 12 months.”
What
happens if an MS patient is also seeing a psychiatrist – does the neurologist
also need to perform a standardized depression screening tool?
p.
42 – “MS is frequently associated with depression, and is currently under
diagnosed and treated.4 Evidence
of under diagnosis of depression in MS patients makes screening vital to
identifying those in need of treatment.“
Depression
is not the only “affective disorder” that is under diagnosed that would benefit
from screening. Pseudobulbar affect (PBA) affects 45.8% of MS patients
according to the PRISM registry (Brooks B.R.Crumpacker D.Fellus J.Kantor D.Kaye R.E.PRISM: A Novel Research
Tool to Assess the Prevalence of Pseudobulbar Affect Symptoms across
Neurological Conditions. (2013) PLoS
ONE, 8 (8) , art. no. e72232).
12. Depression Outcome
Measure
p. 44 – “Percentage of patients aged 12 years and older
with MS who have a score indicating they are better than “moderately depressed”
on a validated screening instrument in past 12 months.”
This
draft measure incentivizes physicians to discriminate against patients with
depression and to not add them to their clinic.
p.
44 – “…reinforce the importance
of medication regimen andbe aware of medication side effects (Level 2) …”
There
is a typographical error: “andbe.”
13. Maintained or
Improved Baseline Quality of Life Measure
p.
47 – ‘Percentage
of patients with MS screened with an age appropriate Quality of Life (QOL) tool
who have maintained or improved their baseline QOL score 12 months from initial
score.”
While
it is true that “improving QOL is a desired outcome,” there are no medications
that have been FDA approved to improve the quality of life of patients with MS.
There are patients who will have a decline in quality of life despite the best
efforts of their caring neurologists – these neurologists should not be thought
of as low quality physicians.
The
wording of the draft measure is confusing because it is not clear whether it
applies to all MS patients or only to those who were screened in the past.
p.
47 – “Measuring QOL and monitoring for maintenance or improvement is expected
to result in improved QOL assessment and prompt timely interventions for
patient identified concerns.”
Spending
too much time worrying about measuring and monitoring scores may actually
detract from the (already diminishing) time spent by an individual patient with
an individual physician.
The
draft measure does not take into account the reality that patients may improve
on some portions of a QOL tool, while regressing on others.
p.
47 – “Existing endorsed measures assess quality of life as a process measure
for a select group of individuals and are not generalizable to the MS
population. (e.g., receiving dialysis …”
The
existing dialysis measure quoted differs drastically from the draft MS measure
since the dialysis measure only asks for patients to receive a quality of life
assessment, while the MS measure expects the patient to maintain or improve
their quality of life score (while always our goal, it is not always
realistic).
It
is apparent that further improving the quality of Medicine offered to all MS
patients is a lofty goal, and one iteration of a draft measurement set will
probably not suffice to meet the complex needs of our patients. Many of these
draft quality measures are better suited as an educational initiative for
patients. Once we further improve the education of the entire MS patient
community, patients will select quality physicians on their own. Patients may
then make their own decisions about staying with a physician or not.
Thank
you for your dedication to our profession and to our patients. Please do not
allow the desire to develop quality measures eclipse the necessity of
developing measures that truly capture quality in practice.
Sincerely,
Daniel Kantor, MD
Immediate Past President
Florida Society of Neurology
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