Advisory Commission Research Articles

Performance Management in Government Internal Audits: Critical Success Factors

This study investigates the factors that impact successful performance management in government internal audit units. Studies show that besides formal compliance with statutory and administrative mandates such as compilation and reporting, public sector performance measures are not utilized for managerial decision making, budgetary allocation and accountability. The National Performance Management Advisory Commission has identified in the Performance Management Framework for State and Local Government, activities that constitute key factors for sustaining performance management. Using 2012 benchmarking data from the Association of Local Government Auditors, this study analyzed the extent to which the uses of government internal audit performance reports, as well as audit performance of the activities identified as key factors in the above-mentioned framework, impact successful audit performance management. Results show that successful performance management is a function of audit oversight body’s commitment, audit staff accountability, availability of adequate resources, as well as the use of audit performance report to monitor achievement against performance objectives, and to coordinate efforts within government. The results also generally confirm both the literature on the low utilization of performance measures and many key factors outlined in the performance management framework.

Is Physician Work in Procedure and Test Codes More Highly Valued Than That in Evaluation and Management Codes?

To determine whether the Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule confers higher value for physician work in procedure and test codes than in Evaluation and Management (E/M) codes. Medicare Payment Advisory Commission previously demonstrated that time for medical services is the dominant element in valuing physician work in the CMS Physician Fee Schedule. In contrast, a more recent analysis suggests that more relative value units (RVUs) per unit time are issued for work in procedure codes than in E/M codes. Both prior analyses had important limitations for evaluating a possible systematic differential valuation of medical services. Data regarding RVUs, physician work times (minutes), and claims were obtained for all active level I Current Procedural Terminology (CPT) codes from 2011 CMS files. Linear regression was used to assess the associations of work time components and CPT category with work RVUs, including a model that weighted codes by the number of claims. Included in the analysis were 6522 CPT codes (87 E/M codes, 6435 procedure/test codes). Compared with E/M codes, procedure/test codes did not have a significant difference in work RVUs adjusting for time (-0.631; 95% confidence interval, -1.427 to 0.166). The analysis also did not indicate a work RVU advantage specifically for Surgical CPT codes compared with E/M adjusting for time (-0.760; 95% confidence interval, -1.560 to 0.040). This pattern was not altered after weighting codes by the number of claims, indicating that an increase in RVUs per minute was not concentrated in a small number of highly utilized procedure codes. We did not find evidence of a systematic higher valuation of physician work in procedure/test codes than in E/M codes in the CMS RVU system.

Two Nations, Revisited: The Lynching of Black and Brown Bodies, Police Brutality, and Racial Control in ‘Post-Racial’ Amerikkka

In 1968, President Lyndon B. Johnson established the National Advisory Commission on Civil Disorders (NACCD) to examine the 1967 race riots that were taking place in Los Angeles, Chicago, Newark, and Detroit that erupted in the mid-1960s. That report, officially labeled the Kerner Report, outlined structural inequalities in America that privileged whites over other racial and ethnic groups; the report concluded that the United States was headed toward two separate and unequal societies: black and white. Forty-seven years after the Kerner Report where do we stand? In this article, I revisit recent events on police violence toward minorities and give consideration to some thoughts moving forward.

“To Judge Harshly”: The Troubled Legacy of America’s Struggle with Poverty

About Thomas Kiffmeyer Thomas Kiffmeyer received his undergraduate degree from Miami University (Oxford, Ohio) in 1985 and his PhD from the University of Kentucky in 1998. Currently, he is an Associate Professor of History at Morehead State University. His publications include Reformers to Radicals: The Appalachian Volunteers and The War on Poverty (University Press of Kentucky) and We Are Ordered To Do Everything: The National Advisory Commission on Rural Poverty and American Social Thought (Register of the Kentucky Historical Society). Thomas Kiffmeyer

Hospital readmissions reduction program.

Hospital readmission measures have been touted not only as a quality measure but also as a means to bend the healthcare cost curve. The Affordable Care Act (ACA) established the Hospital Readmission Reduction Program (HRRP) in 2012. Under this program, hospitals are financially penalized if they have higher-than-expected risk-standardized 30-day readmission rates for acute myocardial infarction, heart failure, and pneumonia. The HRRP has garnered significant attention from the medical community, both positive and negative. Here, we describe the reasons the HRRP was implemented, the penalties levied, the impact it has had on transitional care and readmissions, the pros and cons of the policy, and its future. Hospital readmissions are associated with unfavorable patient outcomes and high financial costs.1,2 Causes of readmissions are multifactorial, and rates vary substantially by institution.3,4 Historically, nearly 20% of all Medicare discharges had a readmission within 30 days.1 The Medicare Payment Advisory Commission has estimated that 12% of readmissions are potentially avoidable. Preventing even 10% of these readmissions could save Medicare $1 billion.5 Therefore, reducing hospital readmissions has been made a national priority. In 2008, the Medicare Payment Advisory Commission recommended to Congress that the Centers for Medicare & Medicaid Services (CMS) begin confidentially reporting readmission rates and resource use to hospitals and physicians.6 In 2009, CMS began publicly reporting hospital-level readmission rates, which were added to the Hospital Compare Web site.7 Before 2012, hospitals had little direct financial incentive to reduce readmissions. For Medicare beneficiaries with inpatient stays, hospitals receive payment with the inpatient prospective payment system (IPPS). This payment, based on a diagnosis-related group (DRG), covers the inpatient stay and any outpatient diagnostic and admission-related outpatient nondiagnostic services provided by the institution on the date of the patient’s admission or within 3 days immediately …

Improving the Arbitration Procedure under the EU Arbitration Convention (2)

This article analyses the functioning of the arbitration procedure under the European Union (EU) Arbitration Convention and whether improvements to this procedure are possible. This article constitutes the second part of the article of which the first part was published in issue 2015-I of EC Tax Review. Part I thereby focused on the formal aspects of the arbitration procedure, namely the establishment of the advisory commission and the process of appointment of its members, as well as the secrecy obligation and costs of the procedure. Part II of this article will analyse in more detail the functioning of the advisory commission and the content of the opinion to be rendered. The article thereby takes into account previous improvements to the arbitration procedure, as implemented by the (revised) Code of Conduct on the effective implementation of the EU Arbitration Convention, as well as current discussions within the EU Joint Transfer Pricing Forum relating hereto.

Invited Commentary

These authors [1Murarka S. Lazkani M. Neihaus M. et al.Comparison of 30-day outcomes of transfemoral versus transapical approach for transcatheter aortic valve replacement: a single-center US experience.Ann Thorac Surg. 2015; 99: 1539-1545Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar] report their single-center experience with both transfemoral (TF) and transapical (TA) approaches for transcatheter aortic valve replacement (TAVR) in a United States population. Through a retrospective study design and selective matching of patient characteristics, two selected subpopulations are compared. The authors hypothesize that 30-day survival is at parity and that procedural efficiency (with metrics of procedure time, contrast volume, and fluoroscopy exposure) is enhanced with the TA approach. The authors are to be congratulated for (1) reinforcing that the current practice of using a TA approach when barriers to TF TAVR are present is, in fact, safe; for (2) reinforcing the observation that permanent pacemaker implantation is associated with a significant hazard of death (hazard ratio 7.1); and for (3) reinforcing the utility of efficiency in our literature. This third construct, the use of efficiency as an outcome, is intriguing. Efficiency is casually referenced daily. In an academic context, efficiency evolves into a more elusive but important paradigm. In a concerted effort to improve health care efficiency reporting, the Agency for Healthcare Research and Quality (AHRQ) enlisted a multidisciplinary team at RAND to categorize and evaluate health care efficiency measures (AHRQ publication No. 08-0030, April 2008). The systematic underperformance in efficiency assessment may be explained in part by the varying definitions of efficiency provided by vested entities. The Institute of Medicine in 2001 defined it as avoiding waste of equipment supplies, ideas, and energy. Economic theory has three definitions (technical, productive, and social). The Ambulatory Care Quality Alliance, the Government Accountability Office, and the Medicare Payment Advisory Commission each embrace institutionally centric definitions of efficiency. A notable takeaway from this white paper is the importance of “perspective” from which the efficiency is measured. Does the efficiency benefit society, the health care system, the provider, the procedure, the hospital, or the patient? Thus, the perspective from which efficiency is measured requires explicit acknowledgment. In the current report, the efficiency of aortic stenosis treatment was evaluated from the patient’s perspective. The authors propose that efficiency was improved with the TA procedure because the outcome was equal and the resource utilization (fluoroscopy time, contrast volume, and procedure time) were diminished: thus, increased efficiency. This may be a valid statement from the patient’s perspective for the procedure itself. Unfortunately, these are likely marginal costs, and they fail to represent meaningful utility. The argument for efficiency with TA becomes increasingly fragile when we consider that the length of stay (which trends toward a TF benefit) as an extra day in the hospital may supersede the benefits of procedure time, contrast volume, and fluoroscopy time from a broader health care perspective. Importantly, the realized cost data were not reported, so this weakens the generalizability of the authors’ claim of efficiency with respect to the TA approach for aortic stenosis. The authors are to be applauded for taking a bold step into the concept of efficiency. In the future, our readership and our regulatory bodies will expect this enhanced analytic structure when they evaluate therapeutic strategies. A universal approach to reporting health care efficiency will improve the influence of this research. Comparison of 30-Day Outcomes of Transfemoral Versus Transapical Approach for Transcatheter Aortic Valve Replacement: A Single-Center US ExperienceThe Annals of Thoracic SurgeryVol. 99Issue 5PreviewThe optimal access route for transcatheter aortic valve replacement (TAVR) remains debatable. We compared early safety outcomes at 30 days between the transfemoral (TF) and transapical (TA) approaches in a single, high-volume center in the United States. Full-Text PDF

Improved integrated care is key, reports Sandy Hook Advisory Commission

Improved integrated care is key, reports Sandy Hook Advisory Commission

Improving the Arbitration Procedure under the EU Arbitration Convention (1)

This article analyses the functioning of the arbitration procedure under the EU Arbitration Convention and whether improvements to this procedure are necessary and possible. The article thereby takes into account previous improvements to the arbitration procedure, as implemented by the (revised) Code of Conduct on the effective implementation of the EU Arbitration Convention, as well as current discussions within the EU Joint Transfer Pricing Forum relating hereto. Part I of this article analyses the establishment of the advisory commission and the process of appointment of its members, as well as the secrecy obligation and costs of the procedure. Part II will analyse in more detail the functioning of the advisory commission and the content of the opinion to be rendered. Each part ends with a conclusion.

Human capital and audit independence

In 2007 the US Department of the Treasury established the Advisory Committee on the Auditing Profession "to assist the Department in evaluating the sustainability of a strong and vibrant auditing profession." In establishing the Committee, the Department expressed its concern with the quality of the 'human capital' constituting the independent audit profession, suggesting that it was not good enough. The Advisory Commission gave the work of considering the educational qualifications and needed educational improvements to the accounting profession which then organised The Pathways Commission which members were current accounting academicians and members from the practicing independent audit profession. Unremarkably, the Commission's recommendations were to not change anything, or at least, not to make any significant changes. This paper recommends that the legal profession - that is, lawyers with a financial accounting expertise - take over the independent audit profession.

Risk assessment in clinical trials: it don't mean an ethical thing if it ain't got that probability ring!

Since clinical trials are conducted in a context of inherent uncertainty, the assessment of risk is central to their scientific design and ethical conduct. Substantial evidence points to a pervasive misunderstanding of the concept of risk within the clinical research community that results in risk assessment being one of the least satisfactory parts of trial protocols. At its core, the problem rests with the fact that medicine, unlike the social sciences, economics, and philosophy which now pursue their respective scientific methodologies grounded in a probabilistic paradigm, remains wedded to a deterministic paradigm. However, it is from within the probabilistic rather than the deterministic paradigm that justification for conducting clinical research is to be found. Since prospectively their outcomes, including benefit and harm, are unknowable, clinical trials take place under conditions of uncertainty. In recognizing this, the Belmont Report (Belmont) [1] called for the assessment of risk involved in participating in clinical trials with three goals in mind. The first, for clinical researchers, is to determine whether the research design poses minimal risk of harm to participants. The second goal, for prospective participants, is to help them to decide whether to participate in the trial. The third goal, for institutional review boards (IRB’s), is to enable members to determine whether the risk of harm relative to the likelihood of benefit favors benefit over harm for trial participants. By way of confirmation, the National Bioethics Advisory Commission (NBAC) declared that “risk is a central organizing principle, a filter through which protocols must pass” [2] if scientific validity, patient participation, and IRB approval are to be considered reasonable. But given the centrality of risk assessment to scientific validity, a patient’s informed consent to participation and IRB approval, why in a 2002 study would up to two-thirds of respondents find that trial protocols provide insufficient information regarding the likelihood of both risks and benefits [3]? Why is it that so few protocols pass through the NBAC filter and in the way envisaged by Belmont? Closer reading of Belmont also reveals that risk assessment requires a specific understanding of the concept of risk which: refers to a possibility that harm may occur. However, when expressions such as ‘small risk’ or ‘high risk’ are used, they usually refer (often ambiguously) both to the chance (probability) of experiencing harm and the severity (magnitude) of the envisioned harm [1, pg7]. (Cont.)

Angus Campbell: A Pioneer in Social Indicators and Social Reporting

Angus Campbell (1910–1980) was a pioneer in studies of social indicators of wellbeing or quality of life research. He was born in Indiana, raised in Portland, Oregon, earned his B.A. and M.A. from the University of Oregon in 1931 and 1932, respectively. In 1936 he completed his Ph.D. at Stanford University under E.R. Hilgard. In 1946 Rensis Likert and some colleagues convinced the University of Michigan to establish the Institute for Social Research. For the first 25 years of ISR’s existence, Likert was its Director and Campbell was Director of its’ Survey Research Center. When Likert retired in 1970, Campbell replaced him. In 1967 the Survey Research Center was asked by the National Commission on Civil Disorders to undertake a study of race problems in 15 major cities, some of which had experienced severe disturbances in the previous summer. This led to publication with H. Schuman of “Racial Attitudes in 15 American Cities” in Supplemental Studies for the National Advisory Commission on Civil Disorders (1968). Three years later Applied Research Quality Life (2014) 9:781–782 DOI 10.1007/s11482-014-9325-3

Calling All Doctors

Calling All Doctors

Integrating Care at the End of Life

Integrating Care at the End of Life

The National Commission on Physician Payment Reform: Recalibrating Fee-for-Service and Transitioning to Fixed Payment Models

The National Commission on Physician Payment Reform: Recalibrating Fee-for-Service and Transitioning to Fixed Payment Models

Water in the West

DOI 10.1515/cjpp-2013-0043 Calif. J. Politics Policy 2014; 6(1): 61–102 Commentary Andrew Fahlund, Min L. Janny Choy* and Leon Szeptycki Water in the West Keywords: climate change; ecosystem services; environmental flows; financing; green infrastructure; water; water-energy; water governance; water infrastructure; water management; water markets; water policy; western water; western history. *Corresponding author: Min L. Janny Choy, Water in the West, a joint program of the Stanford Woods Institute for the Environment and the Bill Lane Center for the American West, Stanford ­University, Stanford, CA, USA, e-mail: jannychoy@stanford.edu, website: www.waterinthewest. stanford.edu Andrew Fahlund and Leon Szeptycki: Water in the West, a joint program of the Stanford Woods Institute for the Environment and the Bill Lane Center for the American West, Stanford University, Stanford, CA, USA 1 Introduction “One cannot be pessimistic about the West. This is the native home of hope. When it fully learns that cooperation, not rugged individualism, is the quality that most characterizes and preserves it, then it will have achieved itself and outlived its origins. Then it has a chance to create a society to match its scenery.” ― Wallace Stegner The Western United States is a diverse region of the country, with little in common between places like Cody, Wyoming and Palo Alto, California. One condition common to the region – with the exception of a few coastal communities – is aridity. It seems odd to characterize an entire region by what it lacks, but water has always been the most consistent and frequently cited tie that binds the West. Although a long history of papers, reports, and books have analyzed issues around western water, 1 the last official comprehensive examination of the subject was published 15 years ago. In 1996, Congress chartered the Western Water Policy Review Advisory Commission (Commission) to publish a report, Water in the West: 1 Marc Reisner, Cadillac Desert: The American West and Its Disappearing Water (1986); Stewart L. Udall, Beyond the Mythic West (1990); Wallace Stegner, The American West as Living Space (1987).

Viewpoint: The case for a foreign worker advisory commission

This paper outlines the case for an independent Foreign Worker Advisory Commis-sion (FWAC) to assemble and develop data and research to assist the administration and Congress make better and more timely decisions on employment-based migration (EBM), a relatively small (14 per cent in 2010) component of total immigration. An independent, professional FWAC should be an important component of comprehen-sive immigration reform. Indeed, the FWAC should be established and operational before any substantive changes are made in current foreign worker programs. The United States should, however, immediately improve the enforcement of the rights of foreign and domestic workers, simplify and modernize administrative procedures, and strengthen data relevance and reliability.

Editorial: Expert commissions and migration policy making

More countries are turning to expert commissions to assess labour market and demo-graphic data to help to answer the fundamental migration questions of how many, from where, and in what status newcomers should arrive. Britain has had a Migration Advisory Commission since 2008, and most US immigration reform proposals include commissions to assess labour market, demographic, and other data to provide advice or set quotas on the number of immigrants and temporary foreign workers admitted.

Invited Commentary

In October 2012, Medicare began a program designed to penalize hospitals deemed to have an excess number of patients re-admitted within 1 month of hospital discharge. Starting October 1, 2013, 2,225 US hospitals will have payments reduced for a year. The penalty can be as much as 2% of Medicare payments, although the average penalty is 0.38%. In at least 10 states, 80% of hospitals will be subject to some degree of financial loss. The total annual financial impact on US hospitals is projected to be $227 million. The Medicare Payment Advisory Commission has estimated that 12% of Medicare patient readmissions may be avoidable. Reducing 10% of unnecessary admissions could save an estimated $1 billion. The penalties noted above apply to readmissions of Medicare patients following hospitalization for myocardial infarction, congestive heart failure, or pneumonia. It is anticipated that other conditions, including cardiac surgery, will be added to this list soon. It is in this setting that the article by Brown and colleagues [1Brown J.R. Parikh C.R. Ross C.S. et al.Impact of perioperative acute kidney injury as a severity index for thirty-day readmission after cardiac surgery.Ann Thorac Surg. 2014; 97: 111-117Abstract Full Text Full Text PDF Scopus (45) Google Scholar] is particularly timely. The authors analyzed factors influencing readmission after cardiac surgery in 2,209 consecutive patients who underwent coronary artery bypass grafting or valve surgery in the 7 hospitals of the Northern New England Cardiovascular Disease Study Group (NNE) over a recent 18-month period. The investigators used administrative data to identify patients readmitted within 30 days of hospital discharge. To refine their predictive model, they used established definitions to quantify acute kidney injury (AKI) during the index hospitalization, and applied this information to a risk model designed to predict readmission. The authors found a significant association between stage of AKI and 30-day readmission, and also found that models predicting readmission were significantly improved by adding AKI stage. This suggests that perioperative factors (such as severity of postoperative AKI) should be considered when assessing the risk for readmission after cardiac surgery. The data raise additional questions. Were some patients readmitted to hospitals outside the NNE? Did type of discharge (ie, to home, inpatient rehab facility, long-term acute care hospital, etc) influence readmission rate? More in-depth analysis of the reasons for readmission will be important in developing strategies for improvement. Readmission after cardiac surgery increases health care costs and efforts to safely reduce this phenomenon deserve further study. This work represents an important step toward identifying patients at risk for readmission and in stratifying patients at increased risk to yield a more equitable application of public policy rules. Impact of Perioperative Acute Kidney Injury as a Severity Index for Thirty-Day Readmission After Cardiac SurgeryThe Annals of Thoracic SurgeryVol. 97Issue 1PreviewOf patients undergoing cardiac surgery in the United States, 15% to 20% are re-hospitalized within 30 days. Current models to predict readmission have not evaluated the association between severity of postoperative acute kidney injury (AKI) and 30-day readmissions. Full-Text PDF

Recommendations of the Medicare Payment Advisory Commission (MEDPAC) on the Health Care Delivery System: The Impact on Interventional Pain Management in 2014 and Beyond

Continuing rise in health care costs in the United States, the Affordable Care Act (ACA), and a multitude of other regulations impact providers in 2013. Despite federal spending slowing in the past 2 years, the Board of Medicare Trustees believes that cost savings are only achievable if health care providers are able to realize productivity improvements at a quicker pace than experienced historically. Consequently, the re-engineering of U.S. health care and bridging of the divide between health and health care have been proposed beyond affordable care. Thus, the Medicare Payment Advisory Commission (MedPAC) envisions alignment of Medicare payment systems to eliminate variable rates for the same ambulatory services provided to similar patients in different settings, such as the physician’s office, hospital outpatient departments (HOPDs), and ambulatory surgery centers (ASCs). MedPAC believes that if the same service can be safely provided in different settings, a prudent purchaser should not pay more for that service in one setting than in another. MedPAC is also concerned that payment variations across settings encourage arrangements among providers that result in care being provided in high paid settings. MedPAC recommends that payment rates be based on the resources needed to treat patients in the most efficient setting, adjusting for differences in patient severity, to the extent the severity differences affect costs. MedPAC has analyzed the costs of evaluation and management (E&M) services and the differences between providing them in a HOPD setting compared to a physician office setting, echocardiography services, and multiple services provided in ASCs and HOPDs. MedPAC has shown that for an established patient office visit (CPT 99213) provided in a free-standing physician’s office, the program pays the physician 70% less than in HOPD setting with a payment for physician practice of $72.50 versus $123.38 for HOPD setting. Similarly, for a Level II echocardiogram, HOPD costs 141% more for the same service than a free-standing office ($188.31 versus $452.89). For interventional techniques, Medicare payments vary from physician office to HOPD setting, with $211.96 in an office setting, $407.28 in ASC setting, and $655.62 in HOPD for procedures such as epidural injections. The MedPAC proposal for changing HOPD payment rates for services would reduce program spending and result in beneficiary cost sharing by $900 million in one year. On average, hospitals’ overall Medicare revenue will decline by 0.6% and HOPD revenue would fall by 2.7%. Further, MedPAC provided a specific example that aligning payment rates between HOPDs and freestanding offices only for cardiac imaging services would reduce program spending and beneficiary cost sharing by $500 million in one year. In estimating the savings that would be realized by equalizing payment rates between HOPDs and ASCs for certain ambulatory surgical procedures, MedPAC have shown potential Medicare program spending and beneficiary cost savings to be about $590 million per year. The impact of the proposed policies that are discussed in this manuscript would result in savings of approximately $1.5 billion per year for Medicare. MedPAC also has recommended a stop-loss policy that would limit the loss of Medicare revenue for those hospitals. Key words: Medicare, health care delivery system, Medicare Payment Advisory Commission (MedPAC), hospital outpatient departments (HOPDs), ambulatory surgery centers (ASCs), physician office practices