1. Intersection of Surgical Outcomes and Medical Education A CMO’s Perspective How can I get housestaff to think about value-based clinical medicine using outcomes data? Can outcomes data be used to incorporate a culture of quality improvement into surgical training?

2. Medical Education My CFO’s Perspective Declining hospital margins Inefficiencies in the care model Declining GME funds Growing emphasis on education over service Time away for didactics, simulation “Explain to me again why I would rather pay for a resident than a PA or NP”

3. © Copyright. All Rights Reserved. Cost of Care.3 Congress should authorize the Secretary to change Medicare’s funding of graduate medical education (GME) to support the workforce skills needed in a delivery system that reduces cost growth while maintaining or improving quality. The indirect medical education (IME) payments above the empirically justified amount should be removed from the IME adjustment and that sum would be used to fund the new performance-based GME program. To allow time for the development of standards, the new performance-based GME program should begin in three years (October 2013).

4. Value-Based Residency Training and Reimbursement: CMMI Project Proposal PI: Joel Katz MD Hypothesis: A new model of hospital reimbursement can improve: 1) Metrics of health status among patients cared for by trainees 2) Attainment and utilization of competencies directly related to value (quality per unit cost) and lead to more cost-efficient investments in physicians in training

5. Direction Of Health Reform Is Uncertain.... Global Capitation Fee for Service P4P Medical Home Bundled Payments Adapted from Dr. James Mongan presentation 5/26/2009 Level of financial risk borne by provider Level of financial risk borne by payor...but all models involve performance measurement and accountability

6. Bundled Procedures Surgeon-specific Metrics M&M LOS Readmission rates Use of home care, PT, SNF, rehab Cost data Access Patient satisfaction Compliance with standardized pathway Site of care

7. Procedure Cost Assessment 7 MDCasesCMI Total OR Time Team SuppliesImplantsRecoveryPharmRadOther A2373.63$7,572$1,029$2,652$2,779$1,113$6$18$1,204 B913.85$8,965$1,715$3,086$3,025$1,140$29$39$1,522 C904.37$10,392$1,668$4,106$3,455$1,163$11$46$1,508 D763.96$8,661$1,498$2,550$3,625$988$6$80$1,423 E563.7$8,084$1,265$2,680$2,920$1,219$6$76$1,251 F463.82$11,457$1,838$2,570$5,821$1,228$22$360$1,800 G293.97$8,822$1,802$2,789$3,210$1,022$4$43$1,545 H263.78$11,543$1,490$3,514$5,456$1,082$10$229$1,462 I193.53$8,047$1,498$2,319$3,269$961$206$16$1,312 Average Direct Cost per Inpatient Discharge Total Knee Replacement - OR Related Costs - FY11

8. Surgeon-specific Metrics The Next Generation?

9. Porter ME. NEJM 2012

10. QPID Appropriate Procedure Order : Evidence Based Guidelines >50% Stenosis as determined by ultrasound or angiogram and symptomatic Print Personalized Consent Schedule Surgery >80% Stenosis as determined by ultrasound or angiogram and asymptomatic Patient has received a decision aid Complex case (write exception below) Risk Calculator: If guideline criteria not met, but patient still requires surgery, add justification here Procedure Decision Support Carotid Stenosis Risk of Mortality1.6% Morbidity or Mortality17.0% Long Length of Stay7.7% Short Length of Stay38.4% Permanent Stroke1.1% Prolonged Ventilation8.2% DSW Infection 0.4% Renal Failure 7.6% Reoperation6.7% Print Personalized Consent Schedule Surgery Carotid Stenosis Therapy Step 1: Indications with exceptions Step 2: Perioperative risk assessment Step 3: Shared decision making Step 4: Outputs

11. CPIP: Clinical Process Improvement Leadership Program

12. How do we prepare our residents for what’s coming? Make outcomes analysis routine Give them the tools to improve eg. CPIP, Lean, Toyota Emphasize appropriateness eg. clinic, advanced care planning, palliative care Teach them some finance analysis and accounting Team training and leadership skills Patient experience training

13. The future ain’t what it used to be. Y. Berra