Preparing Surgical Residents for Pay for Performance: A Model for Procedure Outcomes Reporting

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Preparing Surgical Residents for Pay for
PerformanceA Model for Procedure Outcomes
Reporting

• David A. Berg, MD
• Mark J. Seamon, MD
• Carol A. Fisher, BA
• Richard E. Milner, BS

Harsh Grewal, MD Soo Kim, MD Daniel T. Dempsey,
MD Amy J. Goldberg, MD
Department of Surgery Temple University
Hospital, Philadelphia, PA
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Background

• Healthcare in America
• Escalating costs
• Medical quality and safety issues
• Move toward consumer-driven
• Institute of Medicine consensus statements
• To Err is Human Building a Safer Health System,
  2000
• Crossing the Quality Chasm A New Health System
  for the 21st Century, 2001

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Medicare

• Reimbursement based on DRG, REGARDLESS OF QUALITY
  OF CARE DELIVERED
• Current evolution in Congress
• Revise Medicare system
• Base payments on safe, efficient, and effective
  delivery of care
• Solution ? Pay-for-Performance (P4P)

Opelka, 2005
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What is P4P?

• Value-based purchasing for physicians
• Links payments to quality incentives
• Rewards high quality care
• Based on providers quality and safety outcomes
• Physicians responsible for reporting outcomes

Opelka, 2005
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Centers for Medicare and Medicaid Services (CMS)

• Quality reporting / payment programs
• Hospital-based
• Hospital Quality Initiative
• Premier Hospital Quality Incentive
• Physician-based
• Physician Voluntary Reporting Program

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Hospital Quality Initiative

• Goals
• Empower consumers with quality of care
  information to make informed decisions
• Encourage providers and clinicians to improve
  quality of health care
• Distribute objective, easy to understand data on
  hospital performance

www.cms.hhs.gov
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Hospital Quality Initiative

• 20 quality measures
• Acute MI
• Heart Failure
• Pneumonia
• Surgical Infections (2)
• Reporting on measures linked to payments
  hospitals receive for each discharge

www.cms.hhs.gov Greene, 2006
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Premier Hospital Quality Incentive

• Medicare P4P project
• Part of Hospital Quality Initiative
• Voluntary participation
• Quality measures
• Acute MI
• Heart Failure
• Pneumonia
• CABG
• Total hip and knee replacement

www.cms.hhs.gov
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Premier Hospital Quality Incentive

• Bonus payments based on performance for each
  quality measure, awarded to top 20
• 8.9M awarded during 1st year of project
• 3rd year of project
• Reduction in payments for bottom 20

www.cms.hhs.gov / Greene, 2006
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Physician Voluntary Reporting Program

• Goals
• Prevent chronic disease complications
• Avoid preventable hospitalizations
• Improve quality of care delivered
• Implemented January, 2006

www.cms.hhs.gov
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Physician Voluntary Reporting Program

• Starter set of 16 core evidence-based measures
• Endorsed by physicians and medical societies
• Antibiotic prophylaxis
• Thromboembolism prophylaxis
• Use of internal mammary artery in CABG
• Pre-op b-blocker if history of CABG

www.cms.hhs.gov
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Pennsylvania Health Care Cost Containment Council
(PHC4)

• Independent state agency
• Goal quality improvement / cost containment
• Public reporting of outcomes and quality
• Individual hospitals AND SURGEONS
• CABG
• Joint replacement surgery

Nash, 2005
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Pennsylvania Health Care Cost Containment
Council, February, 2006
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Pennsylvania Health Care Cost Containment
Council, February, 2006
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Realities

• P4P initiatives have been implemented by Medicare
• Any reforms to the payment system will likely be
  linked to some kind of performance measurement
  and incentives (Opelka, 2005)
• Understanding P4P will be essential for all
  graduating residents to thrive in this new era of
  medicine

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Are Surgical Residents Ready for P4P?

• Currently, the methods of competency assessment
  do not identify physicians with either inadequate
  or exceptional levels of competence because
  licensure and board certification are typically
  the only methods used
• (Landon, 2003)

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Are Surgical Residents Ready for P4P?

• Residency Review Committee / American Board of
  Surgery
• Dictate only quantity of procedures for residency
  completion and board eligibility
• Evaluation of outcomes left to individual
  residency programs, not systematically monitored

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Goals

• Ease our surgical residents transition to the
  new P4P culture
• Familiarize our residents with the P4P model by
  utilizing individual procedure outcome reports
  for placement of central venous catheters (CVC)

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Methods

• All (10) PGY-2 residents
• Electively placed CVCs
• 7/20/2005 3/10/2006
• Rotations
• Surgical ICU
• General surgery
• Vascular surgery
• Pocket-sized procedure cards
• Monthly feedback

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Results
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CVCs Placed
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CVCs Placed
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Complication Rates
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Complication Rates
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Complications
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Complications
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Conclusions

• Effective means to introduce residents to the P4P
  culture
• Identify residents who may benefit from further
  instruction on CVC placement in surgical skills
  laboratory
• By incorporating self-monitoring with traditional
  aspects of surgical training, residency programs
  can better prepare surgeons for the changes that
  the new P4P philosophy will bring to future
  practice environments

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PHILADELPHIA
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Surgical Care Improvement Project (SCIP)

• National quality partnership sponsored by CMS,
  ACS, and other groups
• Goal ? post-op MM by 25 by 2010
• Surgical site infections
• Adverse cardiac events
• DVT / PE
• Post-op pneumonia

Opelka, 2005
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Ambulatory Care Quality Alliance

• Clinicians, health plans, government agencies
• May, 2005
• 26 quality measures for ambulatory care endorsed
• Priority areas
• Prevention CAD
• Heart failure Diabetes
• Asthma Depression
• Prenatal care Antibiotic overuse/misuse
• Recent creation of surgery and procedure
  workgroup to examine performance measures related
  to procedure-oriented specialties

Opelka, 2005