1. Pay for Performance: Meaningful Metrics and Measures from the Program Director’s Perspective George M. Fuhrman MD Program Director Surgery Atlanta Medical Center APDS Panel March 25, 2011

2. Disclosure Knew nothing about this topic one month ago Knew nothing about this topic one month ago Appreciate the opportunity to participate Appreciate the opportunity to participate Little scientific evidence – formed a personal opinion based on my reading Little scientific evidence – formed a personal opinion based on my reading Apologize to those I offend Apologize to those I offend I am a little bit scared of the future I am a little bit scared of the future

3. Overview Metrics from the Program Director’s Perspective Metrics from the Program Director’s Perspective Metrics from MedPac’s perspective Metrics from MedPac’s perspective Problems with P4P Problems with P4P Lessons from industry Lessons from industry Lesson from Delivery of Clinical Care Lesson from Delivery of Clinical Care Strategies in anticipation of change Strategies in anticipation of change

5. Pay for Performance: Meaningful Metrics and measures from the Program Director’s Perspective P4P is a strategy that potentially can accomplish one of two goals P4P is a strategy that potentially can accomplish one of two goals Financially incentivize productive work – be prepared to grow the prize Financially incentivize productive work – be prepared to grow the prize Contain costs –Fix the size of the prize and redistribute Contain costs –Fix the size of the prize and redistribute

6. P4P – Metrics we understand Resident Recruitment Resident Recruitment ABSITE Scores – high stakes exam!!!! ABSITE Scores – high stakes exam!!!! Resident Faculty and Other Evaluations of Program – 360 degree assessment Resident Faculty and Other Evaluations of Program – 360 degree assessment Is your program taking up a disproportionate amount of GMEC time? Is your program taking up a disproportionate amount of GMEC time? Accreditation Citations Accreditation Citations Technical Skills Technical Skills Fellowship and Job Placement Fellowship and Job Placement ABS QE/CE Performance ABS QE/CE Performance

7. MedPac Perspective Our GME system is the best in the world Our GME system is the best in the world HOWEVER – we are not producing physicians needed for a 21 st century health care delivery system focused on quality, value, and affordability HOWEVER – we are not producing physicians needed for a 21 st century health care delivery system focused on quality, value, and affordability

8. MedPac Perspective Capable of delivering high quality, high value, and efficiently delivered services Capable of delivering high quality, high value, and efficiently delivered services Socioeconomically diverse Socioeconomically diverse Non-specialized Non-specialized Skilled in evidence-based medicine, team based care, care coordination, and shared decision making Skilled in evidence-based medicine, team based care, care coordination, and shared decision making Shift from independent and autonomous practice to a more patient-centered, team based care Shift from independent and autonomous practice to a more patient-centered, team based care

9. Important Metrics according to MedPac Skills essential for delivery system reform Skills essential for delivery system reform Quality measurement and improvement Quality measurement and improvement Evidence based medicine Evidence based medicine Multidisciplinary teamwork Multidisciplinary teamwork Care coordination across settings Care coordination across settings Health information technology Health information technology Utilize the Metrics used to measure the core competencies - Milestones Project Utilize the Metrics used to measure the core competencies - Milestones Project

10. How many angels can dance on the head of a pin?

11. Medicare should NOT presume to prescribe curricular content or teaching method Accrediting organizations Accrediting organizations Certifying boards Certifying boards Government advisory boards Government advisory boards Teaching institutions Teaching institutions Leading health care delivery systems Leading health care delivery systems Insurers Insurers Purchasers Purchasers Patients Patients Residency program directors Residency program directors

12. Unintended Consequences Hewlett-Packard example Pay for performance was INITIALLY successful production increased Pay for performance was INITIALLY successful production increased High performing production teams refused to admit new members perceived to be below their level of expertise High performing production teams refused to admit new members perceived to be below their level of expertise Underperforming groups (e.g. parts delivery) impacted production causing resentment and financial difficulty for employees unable to maintain new higher standards associated with increased pay Underperforming groups (e.g. parts delivery) impacted production causing resentment and financial difficulty for employees unable to maintain new higher standards associated with increased pay Managers spent all of their time reengineering pay systems neglecting primary responsibility of building trust and company commitment Managers spent all of their time reengineering pay systems neglecting primary responsibility of building trust and company commitment

13. Unintended Consequences Too focused on metrics - passover marginal US grad for >95 th percentile USMLE international grad? Too focused on metrics - passover marginal US grad for >95 th percentile USMLE international grad? Too exam focused miss out on technical and communication skills (unless graded) Too exam focused miss out on technical and communication skills (unless graded) Personal tragedy impacts meeting resident ability to meet targets metrics? Personal tragedy impacts meeting resident ability to meet targets metrics? Does the resident that miscarries or divorces jeopardize their training? Does the resident that miscarries or divorces jeopardize their training? Threaten the satisfaction that accompanies helping a resident through a tough patch? Threaten the satisfaction that accompanies helping a resident through a tough patch?

14. Risk Adjustment 2009 APDS keynote speaker Senator Bennett boasted about 1/3 cost to Medicare for providing cardiac care in Salt Lake compared to Miami 2009 APDS keynote speaker Senator Bennett boasted about 1/3 cost to Medicare for providing cardiac care in Salt Lake compared to Miami Our membership pointed out the patient population was not he same so costs were also different Our membership pointed out the patient population was not he same so costs were also different Risk Adjustment Risk Adjustment

15. Miami

16. Salt Lake City

17. Risk Adjustment More headway can be made trying to assess an individual physician’s or hospital’s outcome- based average performance for a a number of patients, with statistical control for socioeconomic and health status More headway can be made trying to assess an individual physician’s or hospital’s outcome- based average performance for a a number of patients, with statistical control for socioeconomic and health status The science of outcome measurements has yet to scale many methodological hurdles The science of outcome measurements has yet to scale many methodological hurdles Uwe Reinhardt economics professor Princeton NY Times October 15, 2010

18. Emory

19. Morehouse

20. Atlanta Medical Center

25. Before we begin to evaluate performance we must define our pay Does your contract spell out the portion of compensation that is education derived? Does your contract spell out the portion of compensation that is education derived? We won’t get to decide on the metrics We won’t get to decide on the metrics Just like a CABG in Salt Lake City is different (risk adjustment) when compared to Miami training surgeons is different across regions and venues Just like a CABG in Salt Lake City is different (risk adjustment) when compared to Miami training surgeons is different across regions and venues Define our performance at point zero and evaluate us on our ability to move the bar Define our performance at point zero and evaluate us on our ability to move the bar

26. Program Directors do not set policy Instead we are forced to adapt and adjust with limited resources – third world surgery Instead we are forced to adapt and adjust with limited resources – third world surgery P4P might be our next duty hour situation P4P might be our next duty hour situation We can craft all of the eloquent responses in the world that will fall on deaf ears but if we get the word from above that P4P is here we adjust or struggle We can craft all of the eloquent responses in the world that will fall on deaf ears but if we get the word from above that P4P is here we adjust or struggle We should try and get a meaningful seat at the table because our future and salaries will depend on it – we should be part of the solution to solve the problem We should try and get a meaningful seat at the table because our future and salaries will depend on it – we should be part of the solution to solve the problem

27. IOM MEDPAC Congres s

28. Conclusions The pie is not going to grow – P4P at best will be revenue neutral. Gamesmanship (ability to create and quantify nebulous metrics) will be rewarded at the expense of the ill prepared The pie is not going to grow – P4P at best will be revenue neutral. Gamesmanship (ability to create and quantify nebulous metrics) will be rewarded at the expense of the ill prepared Define your pay - if the education portion becomes threatened protect the remainder Define your pay - if the education portion becomes threatened protect the remainder Don’t let unintended consequences distract you from your primary responsibility to take care of and educate your residents Don’t let unintended consequences distract you from your primary responsibility to take care of and educate your residents We need a seat at the table when policy is formed – hope to influence, if not, we can be informed We need a seat at the table when policy is formed – hope to influence, if not, we can be informed

29. Sisyphus Duty Hours P4P

30. BLOW UP THE DAMN MOUNTAIN