How to improve care, hit quality metrics for COPD patients

Patients aren’t the only ones who benefit from chronic obstructive pulmonary disease (COPD) treatment. Positive COPD outcomes also help physicians drive more money to their bottom line. That’s because by helping patients manage their COPD symptoms-and, ideally, prevent hospitalizations-physicians may receive a bonus for controlling costs.

COPD is one of many conditions targeted under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the federal law that seeks to improve outcomes and lower costs among patients covered by Medicare.

Beginning in 2020, physicians participating in the Merit-based Incentive Payment System (MIPS), one of two participation tracks under MACRA, will be penalized for costs that exceed anticipated amounts, or rewarded for keeping costs under the projected amounts. The Centers for Medicare & Medicaid Services (CMS) will use 2018 claims data to determine the payment adjustments. 

“I think where physicians have the biggest ‘bang for their buck’ in terms of keeping patients healthy is through education and helping them understand how their life choices will affect their chronic conditions,” says Raemarie Jimenez, CPC, vice president of membership and certification at AAPC, an organization representing medical coders, billers and compliance managers.

When patients understand how to use their rescue inhaler properly, for example, they may be less likely to go to the emergency department and thereby drive up costs unnecessarily, she adds. 

The time to act is now, Jimenez adds. Physicians shouldn’t delay addressing reasons why patients with COPD are admitted and readmitted to the hospital. “Even though the penalty isn’t going to hit you until [2020], if you don’t do the work now, you can’t go back in time and fix it,” she adds.

Patient education affects these four COPD-related quality measures under MIPS:  

• COPD: Prescribing long-acting inhaled bronchodilator therapy

• COPD: Performing spirometry evaluation

• Preventive care and screening: Tobacco use-screening and cessation intervention

• Tobacco use and help with quitting among adolescents

Primary care physicians play an important role in cost-reduction measures because they’re the ones who likely see patients most frequently and can provide critical education about COPD triggers and how to use inhalers, says Rex Mahnensmith, MD, a solo internist in Hartford, Connecticut. Approximately 35% of Mahnensmith’s patients have COPD, and another 30% have asthma.

Use empathy, withhold judgment

Experts agree that cost containment starts with understanding each patient’s unique challenges. This allows physicians to identify the best course of treatment for patients with COPD, many of whom downplay their symptoms and ultimately end up hospitalized when there is no intervention.  

There’s also a stigma associated with COPD, according to Regina Lohr, MPP, senior consultant at Advisory Board, a healthcare consulting company in Washington, D.C. “Patients may feel like they have brought it on themselves through smoking, so they may be embarrassed to seek care,” she says.

However, to help patients with COPD, Lohr says physicians must obtain accurate information regarding the last time the
patient was short of breath or how many cigarettes the patient smokes per day. 

During each patient encounter, Mahnensmith tries to make the patient feel comfortable through eye contact, speaking slowly, and pausing to answer questions in the hopes that patients are at ease disclosing information about symptoms and habits. 

Questions must also address patient limitations. For example, physicians should think about each patient’s ability to manually operate an inhaler, says Mahnensmith. Some people don’t have the dexterity to use a pump inhaler and require a breath-activated inhaler instead, he adds.

Focus on patient education and management

Once physicians identify a course of treatment, patient education becomes critical. For example, when Mahnensmith demonstrates how to use long-acting bronchodilators, he asks patients to repeat the instructions.

He also ensures that patients understand when to use this type of inhaler rather than a rescue inhaler. This involves explaining that long-acting bronchodilators help manage and control COPD symptoms and underlying inflammation, and that patients must use them every day. Rescue inhalers are short-acting devices that quickly address trigger-induced bronchospasm. 

In addition to providing detailed instructions, physicians should observe patients using the inhaler to determine whether their technique is correct, says Steven Weinberger, MD, a pulmonologist. 

Mahnensmith watches patients use their inhalers, and asks them to keep a
record of when they use them. He also monitors preventive inhaler refills and contacts patients who don’t request refills within 60 days. Most inhalers include a fixed number of doses, so when refills aren’t requested, it indicates a patient isn’t using his or her inhaler as prescribed (typically twice per day).

Many patients must also know how to use a nebulizer, says Lohr. “We have certainly seen anecdotally that poor maintenance of the nebulizer can bring patients back to the hospital,” she adds.

Monitoring outdoor air quality is another topic physicians should discuss with patients. For example, Mahnensmith encourages patients with COPD to pay attention to allergy counts and stay inside when counts are high, if possible. Reminding patients about indoor air quality-particularly ensuring the environment is free of dust and mold-is also important, he says.

Finally, make sure that patients know what to do when they experience signs of an acute COPD exacerbation, such as worsening shortness of breath or worsening sputum production, says Weinberger. 

Mahnensmith tells patients to call him before going to the hospital or an urgent care center so he can determine whether they truly need urgent attention or simply a reminder on how to use their rescue inhaler. He also instructs patients to contact him when they begin to use the rescue inhaler more than twice a day, a symptom indicating active inflammation and requiring assessment and additional care. He records these steps in an action plan that’s customized for each patient. 

Understand COPD admission Trends

Transitional care management (TCM)-the process of helping patients transition from the hospital back to the community-not only helps prevent readmissions, it allows physicians to get paid for the time they spend identifying any barriers to treatment. 

That’s because when billing TCM, physicians must meet with patients within seven or 14 days of discharge, depending on the medical complexity of the patient’s condition. Doing so gives physicians the opportunity to identify what may have caused the admission and the barriers that prevent patients from adhering to treatment, she adds. 

Follow up with patients who cancel their post-discharge appointments, says Lohr. Why did the patient cancel? For example, a lack of transportation sometimes can cause patients to forgo meeting with their physician after a hospitalization. She encourages physicians to build connections with local agencies and other organizations that provide support to patients.

Regardless of whether they bill TCM, physicians must be able to monitor patients with COPD who frequently go to the emergency department or urgent care, says Brian Boyce, CPC-I, chief executive officer at ionHealthcare LLC, in Richmond, Virginia, a company specializing in risk-adjustment coding and education. Does the patient need additional education? Should they be taking a different medication? Does the patient have comorbidities that must be considered? Physicians need to ask these questions not only to help patients stay healthy but to reduce costs that could ultimately affect their own payments, he adds. 

Lohr says physicians in independent practice may also want to contact local hospitals to ensure that hospital physicians know how to reach them when a patient presents with a COPD exacerbation. An internist, for example, can shed light on the patient’s symptoms, habits and unique challenges.

Simple steps can make a significant difference, says Lohr. For example, many hospitals and home health agencies now employ COPD navigators who can help patients stay healthy and out of the hospital. By connecting patients with these individuals, physicians are providing patients with local resources who can answer questions and give support, she adds.

“You need to be thinking about how to connect across the care continuum,” Lohr says. “If you’re on the hook for outcomes, then it’s better to be proactive.”