1. Welcome
Ask The Experts
March 24-27, 2007
New Orleans, LA

2. Pay For Performance: What Does it Mean, What will be its Impact in CV Care James Hoekstra, MD Professor and Chairman Department of Emergency Medicine Wake Forest University Health Sciences

3. CMS Core Measures and Pay for Performance Good For Cardiovascular Care
CMS Core Measures and Pay for Performance Good For Cardiovascular Care? James Hoekstra, MD Professor and Chair Department of Emergency Medicine Wake Forest University

4. Healthcare Problem/Opportunity: The Quality Gap
Quality of care and outcomes not optimal
Guideline based therapies underutilized
Outcomes not maximized
Practitioners unaware of guidelines
CQI to practitioners is slow to result in change
Hospital and patient outcomes suffer

5. Time-delay to Treatment and Mortality in 1° Angioplasty for Acute MI: Every Minute Delay Counts
6 RCTs of 1° PCI by Zwolle Group 1994 – 2001 N = 1,791 12 10 8 6 4 2
P <
One-year mortality (%)
Time-Delay to Treatment and Mortality in Primary Angioplasty
for Acute Myocardial Infarction: Every minute counts
Giuseppe De Luca MD, Harry Suryapranata MD, PhD,
Jan Paul Ottervanger MD, PhD, and Elliot M Antman MD*
On behalf of the Zwolle Myocardial Infarction Study Group
Department of Cardiology, ISALA Klinieken, Zwolle, The Netherlands, and *Cardiovascular Division, Brigham and Women’s Hospital, Boston, USA
Submitted to Circt 2003 _________________________________________
About 1800 pts Zwolle 7yr
Highly stat sig exp relationship between sx-ballon and 1 yr mortality
After adjusting for baseline characteristics every 30 min delay from sx-b--- 8% incr in RR of dying at 1 yr
TIME TO REP IS AS IMPORTANT FOR PCI AS IT IS FOR LYSIS
RR = 1.08 [1.01 – 1.16] for each 30 min delay (P = 0.04)
Symptoms – balloon inflation (min)
DeLuca G, et al. Circulation. 2004;109:1223.

6. Average DTB over 100 minutes Despite publicizing DTB guidelines90
Despite publicizing
DTB guidelines
no improvement
noted over 3 years

7. Discharge Medication Use in CRUSADE (After 3 years of CQI by participating hospitals)
100%
93%
90%
87%
80%
70%
68%
60%
40%
20% 0%
ASA
Beta Blockers
ACE-I or ARB*
Any Lipid-
Lowering
Agent#
Clopidogrel
* LVEF < 40%, CHF, DM, HTN # Known hyperlipidemia, LDL > 100 mg/dL
CRUSADE: Quarter 1, 2004-Quarter 4, 2004 (n=39,933)

8. Why P4P(pay for performance) with CMS
Why P4P(pay for performance) with CMS? >60% Annual Hospital Revenue from Medicare/Medicaid
The government is the single largest payor of hospital patient services in the nation. $127 Billion for Medicare hospital patients alone.

9. With a Relatively Fixed $ Pool, CMS recognizes…
With a Relatively Fixed $ Pool, CMS recognizes…. 95% increase in beneficiaries vs 40% reduction in # workers Years 2000 – “Why Should We Pay For Poor Quality?”

10. “Voluntary” Reporting of Hospital Core Measures Performance
Core measures performance reporting mandated for AMI, HF, Pneumonia, CABG, Hip and Knee Surgery.
Public reporting of hospital “scorecards” on core measure data in 5 areas by CMS
Marketing and reputation at stake
Hospitals scramble to develop core measures reporting methods and improve core measures performance

11. Acute Myocardial Infarction (AMI) Core Measure Set
Hospital AMI Core Measures – Initial Release 2002
AMI-1 Aspirin at arrival
AMI-2 Aspirin prescribed at discharge
AMI-3 ACEI for LVSD
AMI-4 Adult smoking cessation advice/counseling
AMI-5 Beta blocker prescribed at discharge
AMI-6 Beta blocker at arrival
AMI-7 Time to thrombolysis
AMI-8 Time to PTCA
AMI-9 Inpatient mortality

12. Quality: Five Clinical Areas
CMS Pay For Performance Demonstration Project The Week in HealthCare, Jeff Tieman, July 14, 2003
Years 1 &
Year
100% $
+2%Bonus $
+2% Bonus
90%
+1%Bonus
+1% Bonus
80% $
70%
Quality: Five Clinical Areas
Coronary artery bypass surgery
Heart attack
Heart failure
Hip and Knee replacements
Pneumonia
60%
50%
40%
CMS will pay out $21 million in bonuses over the three-year project. Under the project, which was given a budgetary green light late last month, hospitals that demonstrate they are in the top 10% of quality in five clinical areas (See slide) will receive a 2% bonus on their Medicare payments. Hospitals in the second 10% will receive a 1% bonus. To help offset the cost of the performance bonuses, the CMS plans in the third year of the demonstration to cut Medicare payments 2% for the poorest performing 10% of hospitals that show no improvement. Those in the next 10% of poorest performers that don’t improve will see their payments decline 1%.
30%
20% $
-1% Reduction
10%
-2% Reduction 0%

14. The New England Journal of Medicine Editorial on February 1, 2007

15. Issues with Pay for Performance
Is there adequate data on core measures??
Linked to outcome?
Definitions?
Able to measure accurately?
Reporting system factors
ICD-9 code criteria vs clinical criteria
Risk/Comorbidity adjustment

16. Unmet Needs of Present Pay for Performance Program
Retrospective Data Gathering
Labor Intensive
Missing Data
Missing Exclusions
No CQI Feedback Loop
Link to physicians
Delay to feedback/education
No Real-Time Data Entry

17. What’s Coming? Do I Hear a Train?
Additions and changes to core measures
New diagnoses/processes
Patient follow up, outcomes
Risk adjustment
Physician Pay for Performance!
July, %

18. Question
&
Answer

19. Thank You!
Please make sure to hand in your evaluation and pick up a ClinicalTrialResults.org flash drive