Compliance gaps swallow revenue, diminish care. Developing standards for care, electronic health records can repair the rift in quality and help grow profits

COLLEGE STATION, TEXAS — Practice owners are losing thousands of dollars due to compliance failures, and the quality of medicine at the point of care is suffering, too.

A study conducted at the Texas A&M Veterinary Medical Teaching Hospital found almost $40,000 in revenue was lost from study subjects because practitioners neglected to recommend treatment options and clients failed to comply with treatment suggestions. If extrapolated to the total number of cases seen by the facility, the potential revenue lost is substantially greater, the report says.

But much of the so-called compliance gap rests squarely on the shoulders of practitioners. The report surmised that recommendation compliance was significantly lower than acceptance and performance compliance, meaning that the full breadth of treatment options are not being discussed with all clients.

"In general, the approach is different from clinicians, even in the same discipline, which probably explains why there would be those types of gaps," says Dr. E. Dean Gage, Dipl. ACVS, executive director and Bridges chair of the Center for Executive Leadership in Veterinary Medical Education and an adviser to the project, which was conducted by DVMs pursuing their master's in business administration and joint DVM/MBA students. "I think they probably come to the same bottom line and probably even the same standards of care, but I think the compliance and how they get there is sometimes questioned."

Table 1. Feline chronic kidney disease (CKD) diagnostic compliance

The solution, Gage says, is to steal a play out of the book of human healthcare delivery. Throughout the past few decades, human healthcare delivery systems have devised myriad multidisciplinary and interdisciplinary guidelines and standards in an attempt to create consistent products that offer the best possible level of care based on historical outcomes, consequently driving satisfactory service and sustainable revenues.

"I think as the clinical faculty in certain disciplines come together to develop what those standards of care and protocols are, then all of that will really consolidate and bring together more effective operations of the hospital, the teaching, the modeling, and clearly would increase the overall quality of the medicine and the income," Gage says.

Many professional associations and specialty medical colleges have issued guidelines, many of them in response to a previous compliance study that showed very similar findings.

Table 2. Feline CKD at-home therapeutic compliance

The American Animal Hospital Association (AAHA) commissioned a compliance study in 2002 via interviews and medical record audits of more than 350 practices nationwide. The results were exceptionally similar: Doctors were not recommending all treatment options due to misperceived financial limitations.

"It's not about the money," says AAHA President Dr. Daniel Aja. "If treatment is recommended by the professional, and you explain why it's important, then clients will usually do it."

The AAHA study found:

• 53 percent of dogs and cats considered to be of senior age were not recommended for screening or diagnostic tests.

• 23 percent of small animals that had Level 2 or higher dental disease had no recommendation for prophylaxis.

• 27 percent of small animals with medical diagnosis that could have been helped by prescription diets did not receive recommendations.

• 11 percent of dogs in areas where heartworm was considered endemic did not receive a recommendation for heartworm testing.

The Texas A&M study concurred.

"Recommendation compliance, gaps in what clinicians are recommending to owners, were the highest," says Dr. Taryn Eaton, an author of the study and an associate veterinarian with the I-20 Animal Medical Center in Arlington. "We all knew this was a problem going into this, but I really didn't realize the magnitude until we started running some of the numbers. Very infrequently did we find that people refused care because of cost."

Table 3. Feline CKD revenue lost due to compliance gaps

As a result of the AAHA study, the association courted certain disciplines to collaborate on standards of care to boost quality at the point of care. As the profession's only hospital accrediting body of almost 900 protocols, procedures and facilities, it increasingly courts professional medical associations and specialty medical colleges to devise standards of care, Aja says.

"I've been reaching out to the specialty colleges in the past two years, and we have an initiative working with them right now trying to bridge the gap between generalists and specialists so that when we talk and when we see a client, they realize that this is a team effort, that we are paired with a specialist to provide the best care for your pet." (See story on AAHA's latest guidelines.)

AAHA's ophthalmology and dentistry guidelines are examples of ways guideline makers share ideas at the drafting table.

Table 4. Canine heartworm disease (HD) diagnostic compliance

The collaborative approach to standardizing medicine was lifted from the template forged by human healthcare during the past few decades when studies continued to show that patient outcomes improved when physicians had a framework that guided patient histories, possible considerations, recommendations and ultimately medical decisions.

Standards and oversight followed. Since 1951, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has provided voluntary accreditation of human healthcare facilities in different disciplines. The American College of Surgeons, American College of Physicians, American Hospital Association, the American Medical Association and Canadian Medical Association created the independent, not-for-profit organization to provide accreditation based on peer-developed and reviewed standards of care.

JCAHO now offers 11 separate certifications, including accreditation for ambulatory care, behavioral care, home care, office-based surgery practices and point-of-care and laboratory testing.

Table 5. Canine HD therapeutic compliance

Others have joined the fray. The Utilization Review Accreditation Commission accredits medical and business procedures, and in 1991, the National Committee on Quality Assurance began accrediting health maintenance organizations and preferred provider organizations.

In the human health world, accreditation is proof that standards have been adopted in a meaningful way, and human healthcare consumers value the respective seals of approval.

Aja says consumers will become increasingly critical when selecting providers of pet health, too.

Table 6. Canine HD revenue lost due to compliance gaps

"People are used to the human hospitals being evaluated, and they assume that the same standards carry over to veterinary medicine," he says. "They expect their quality of care to be better, and it usually is."

The accreditation process illustrates the need for buy-in at the practice level. Guidelines are of little use without adoption by practitioners, and because each practice operates a bit differently, it's necessary that clinicians at each facility revise and adapt existing guidelines so they can be functional enough to improve care.

"There is no way that you can throw a standard of care down at the people who are going to use it," Eaton says. "The real key there is having the evidence to back up your standard and then have the input from the doctors who are going to utilize the standard so that everyone can agree that the process is good for the hospital and good for the patient."

Table 7. Feline obesity recheck revenue

Many of the recommendations adopted on the human side stem from the Institute of Medicine (IOM) of the National Academies, which was founded in 1970 to serve as adviser to the nation to improve health. IOM provides evidence-based and authoritative information and advice concerning health and science policy to policy-makers, professionals, leaders in every sector of society and the public at large. And people listen. IOM reports have shined light on nutrition during pregnancy, inequalities in mental healthcare, obesity, and recently, how technology improves quality at the point of care.

IOM's consistent recommendation that standardized medical technology reduces medical errors and improves clinical quality is echoed by the U.S. Health and Human Services Agency. In 2004, President Bush issued an executive order that created the National Health Information Technology Coordinator to oversee the implementation of standards-based electronic health records of Americans.

Table 8. Canine obesity recheck revenue

Through consistent, accessible and secure medical records, the office of the health IT coordinator is responsible for:

• Ensuring appropriate information to guide medical decisions is available at the time and place of care;

• Improving healthcare quality, reducing medical errors, and advancing the delivery of appropriate, evidence-based medical care;

• Reducing healthcare costs resulting from inefficiency, medical errors, inappropriate care and incomplete information;

• Promoting a more effective marketplace, greater competition, and increased choice through the wider availability of accurate information on healthcare costs, quality and outcomes;

• Improving the coordination of care and information among hospitals, laboratories, physician offices, and other ambulatory care providers through an effective infrastructure for the secure and authorized exchange of health-care information; and

• Ensuring that patients' individually identifiable health information is secure and protected.

It might be a tall order, but numerous studies show that electronic medical records equipped with comprehensive patient data, treatment guidelines and alerts for drug interactions help save lives and improve the quality of care.

Gage agrees, and he says Texas A&M is poised to implement its newly created standards of care because of its medical records infrastructure.

Merging data from patient records allows practices to evaluate all of the differential diagnoses, procedures and outcomes to devise the best possible protocols for each hospital, Gage says.

The patient record "would be considered part of the standard of care," he says. "It does not mean that each diagnostic test, for example, would be ordered each time, but it would mean that it at least would have been considered."

Case in point

The Texas A&M study, "Using Standards of Care to Measure Compliance", measured the frequency of doctor recommendations, client acceptance and client follow-through for patients treated for feline chronic kidney disease, canine heartworm disease, canine and feline obesity management, canine pancreatitis and canine and equine hyposensitization therapy.

In cases reviewed for feline chronic kidney disease, a total of $7,929 was lost due to recommendation and acceptance compliance gaps. When this number was extrapolated for the total number of cases seen by the clinic, about $23,000 in revenue could have been lost due to compliance gaps. The resultant recommendation by authors was that standards of care be implemented to boost recommendation compliance.

For canine heartworm disease, the report calculated about $6,668 was lost due to compliance gaps in diagnostics and therapeutics performed on the cases reviewed (Table 6).

"Similar to feline (chronic kidney disease), the majority of this revenue was lost due to recommendation compliance gaps," the report says, adding that the clinic recommends treatment upon diagnosis instead of referring back to the regular veterinarian.

The report also found a significant number of obese feline and canine patients were not diagnosed. Population estimates indicate that about 4,000 patients should have been diagnosed with obesity, but during 2004, just 102 diagnoses were made.

Of those diagnosed as obese (102), recommendations for weight-loss diets were made in about 30 percent of cases.

In reviewing canine and equine hyposensitization therapy, "significant compliance gaps exist in the refill of antigen injections," the report says. "When extrapolated over the course of the average lifespan of these patients, we found that the VMTH could potentially lose future profits totaling almost $14,000 from missed canine refills and over $10,000 from missed equine refills in only those patients diagnosed in 2002."

"The biggest finding in our study was just that there was so much money and opportunity being lost just based on people not offering or recommending the full scope of the (respective) standard," Eaton says.