1. Pay for Performance- What You Should Know Metropolitan Philadelphia Chapter American College of Surgeons Philadelphia, PA Monday, May 8, 2006

2. I am a salaried employee of the University of Virginia and the American College of Surgeons I have no conflict of interest information to disclose R. Scott Jones, MD, FACS Disclosure

3. The Message The Sovereign, Autonomous Medical Profession failed to adapt to a capitalistic, market driven, health care industry The Government and the Capitalists control the health care industry Surgeons must adapt new strategies Quality and safety are paramount

4. Federal Government Quality Improvement Activities CMS –QIO –NVHRI –Premier HQID –SCIP AQAJCAHO AHRQNQFCDCVADODPHS

5. CMS Quality Initiatives Home Health Quality Initiatives Hospital Quality Initiatives Nursing Home Initiatives Medicaid: Quality in Home and Community Based Services Doctors Office Quality Initiatives Quality in Managed Care

6. CMS Programs Quality Improvement Organizations (QIO) Surgical Care Improvement Project (SCIP)

7. SCIP Goal To reduce surgical mortality and morbidity 25% over 5 years by measuring processes of care and outcomes for 4 targets: –Surgical Site Infections –Adverse Cardiac Events –DVT and PE –Post Op Pneumonia

8. National Voluntary Hospital Reporting Initiative Launched by AHA, FAH, and JCAHO NQF, JCAHO, CMS, and AHRQ provide technical assistance and develop or identify quality measures and Make the information accessible, understandable, and relevant to the public 1,400 Hospitals Participating 20 Quality Indicators Public Reporting

9. Premier Hospital Quality Incentive Initiative Demonstration CMS Partnership with Premier Inc., a nationwide organization of not-for-profit hospitals Quality measures proposed by QIOs, JCAHO, NQF, and Premier: 300 Hospitals Hospitals in top decile get 2% bonus Hospitals in 2 nd decile get 1% bonus Hospitals in 9 th decile get 1% penalty Hospitals in 10 th decile get 2% penalty

10. Physician Voluntary Reporting Program (PVRP) Announced by CMS (Medicare) –October 28, 2005 Mark McClellan, MD, PhD –…an important component of delivering high quality care is the ability to measure and evaluate quality.

11. Physician Voluntary Reporting Program Reporting Infrastructure –Begins January 2006 –EHRs the Goal –Pre-Existing Claims Based System –HCPCS Codes (G-Codes) Quality Improvement Organizations (QIO) Will Assist Physicians

12. Physician Voluntary Reporting Program Quality Measures –16 –Arranged in Sets Multiple G Codes in Each Set –Each Measure Set Has a Numerator and a Denominator –CMS Will Provide Performance Feedback to Physicians

13. Physician Voluntary Reporting Program Measures Aspirin at arrival for acute myocardial infarction Beta blocker at time of arrival for acute myocardial infarction Hb A1c control in patient with Type I or Type II diabetes mellitus Low density lipoprotein control in patient with Type I or Type II diabetes mellitus

14. Physician Voluntary Reporting Program Measures High blood pressure control in patient with Type I or Type II diabetes mellitus Angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker therapy for left ventricular systolic dysfunction Beta blocker therapy for patient with prior myocardial infarction Assessment of elderly patient for falls

15. Physician Voluntary Reporting Program Measures Dialysis dose in end stage renal disease patient Hct level in end stage renal disease patient Receipt of autogenous arteriovenous fistula in end-stage renal disease patient requiring hemodialysis Antidepressant medication during acute phase for patient diagnoses with new episode of major depression

16. Physician Voluntary Reporting Program Measures Antibiotic prophylaxis in surgical patient Thromboembolism prophylaxis in surgical patient Use of internal mammary artery in coronary artery bypass graft surgery Preoperative beta blocker for patient with isolated coronary artery bypass graft

17. Antibiotic Prophylaxis in Surgical Patient G 8152- Patient documented to have received antibiotic prophylaxis one hour prior to incision (two hours for vancomycin) G 8153- Patient not documented to have received antibiotic prophylaxis one hour prior to incision G 8154- Clinician documented that patient was not eligible candidate for antibiotic prophylaxis one hour prior to incision

18. Thromboembolism Prophylaxis in Surgical Patient G 8155- Patient with documented receipt of thromboembolism prophylaxis G8156- Patient without documented receipt of thromboembolismlism prophylaxis G 8157- Clinician documented that patient was not eligible candidate for thromboembolism prophylaxis measure

19. Capitalist Control of Medicine Market Forces Managed Care Financial Power Legislative Power

20. Corporate Control of Healthcare America’s Health Insurance Plans- AHIP Pharmaceutical Research and Marketing Association- PhRMA AdvaMed American Hospital Association- AHA

22. Quality Surgical Care Correct Diagnosis Proper Staging Proper Risk Assessment –Disease –Treatment Proper Treatment –Best Evidence –Best Technology –Best Technique

23. Quality Surgical Care Proper Outcome –Survival –No Complications –Disease Cured –Symptoms Relieved –Function Restored –Death with Dignity in Mortal Diseases

25. ACS Databases National Cancer Data Base (NCDB) National Trauma Data Bank (NTDB) American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP)

26. National Surgical Quality Improvement Program Developed in Veterans Administration-1992 –Shukri Khuri, MD, Jennifer Daly, MD, Bill Henderson, PhD VA-ACS Collaboration VA NSQIP ACS NSQIP

27. THE NSQIP DATABASE Preoperative Data –10 demographic variables –40 clinical variables –12 laboratory variables Intraoperative Data –15 clinical variables Postoperative Data –30-day postoperative mortality –20 categories of 30-day postoperative morbidity –Length of hospital stay PATIENTS UNDERGOING MAJOR SURGERY

28. *: Statistically significant high outlier (inferior performance) #: Statistically significant low outlier (superior performance) 1 0 2 3 NSQIP Annual Report Mortality O/E Ratios for All Operations

29. ACS NSQIP 80 Hospitals currently participating Enrolling 6-8 hospitals monthly

30. So What About Pay for Performance?

31. Surgeon Compensation in the United States Free market fee-for-service Usual and customary fees Organized regulation by government and health insurance industry

32. Medicare 1980’s- Customary, prevailing, and reasonable charges –Medicare reimbursement for physicians increased at a 15% compound rate (2X GNP) 1986- PPRC 1992- RBRVS –Physician work –Practice expense –Professional liability –Geographical factors –Conversion factor (CF)

33. The RBRVS Conversion Factor Determined by the government or the corporations by methodologies that became, for practical purposes, arbitrary Market forces will not directly determine the value of physician services

34. Pay for Performance On Thursday, July 21, 2005 Senator Grassley and Senator Baucus introduced legislation to link Medicare reimbursement to quality of care. –Report quality data –Improve quality –Meet quality thresholds

35. Pay for Performance CMS AMA Consortium NQFAQA

36. ACS Cancer Measures Submitted to the NQF Breast Cancer –Breast conserving surgery is followed by radiation to the breast in women under age 70 –Combination chemotherapy considered or administered within 8 weeks of definitive surgery for women with hormone receptor negative breast cancer greater than 1 cm in greatest diameter

37. ACS Cancer Measures Submitted to NQF Breast Cancer –Tamoxifen or third generation aromatase inhibitor considered for or administered to patients with hormone receptor positive stage I and stage II/III disease

38. ACS Cancer Measures Submitted to NQF Colorectal Cancer –Resected colon speciman contains at least 12 regional lymph nodes histologically examined –Adjuvant chemotherapy is considered or administered to patients with lymph node positive colon cancer –Chemotherapy and/or radiation therapy considered or administered for surgically resected rectal cancer

39. Measure Specifications- Minimum Node Examination Name of Measure –Resected colon specimem should have at least twelve lymph nodes histologically examined. Numerator/Denominator –Numerator- patients having at lease twelve lymph nodes histologically examined –Denominator- Patients undergoing surgical procedure for colon cancer Data Sources –Pathology report and surgical report

40. Measure Specifications- Minimal Node Examination Data Elements, Definitions,and Allowable Values –Surgical Procedure Segmental Resection Hemicolectomy Total Colectomy Total Proctocolectomy –Number of Regional Lymph Nodes Pathologically Examined Possibilities Data Analysis Logic and Method Risk- Adjustment Method Cohort Definition and Sampling Method References

41. Quality Indicators/Value-Based Practice Professional Societies AMA Consortium NQF AQA Health Insurance Industry Practicing Physicians

42. Pay for Performance The corporations and government control payment and will protect their interests relentlessly Linking reimbursement to quality will require unprecedented collaboration Surgeons must approach this challenge with data, discipline, and commitment to protect the interests of the sick

43. Assessment of the Quality of Surgical Care: The Surgeon’s Imperative Protect the Interests of the Sick –Self Interest –Corporate Interests Profit –Government Interests PoliticsBureauocracy Live by the Scientific Method –Evidence-based Medicine –Reliable Data Recognize the Importance of Systems

44. Thank You