Pay for Performance- What You Should Know

1
Pay for Performance- What You Should Know

• Metropolitan Philadelphia Chapter
• American College of Surgeons
• Philadelphia, PA
• Monday, May 8, 2006

2
Disclosure

• 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

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
• AQA
• JCAHO

• AHRQ
• NQF
• CDC
• VA
• DOD
• PHS

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 2nd decile get 1 bonus
• Hospitals in 9th decile get 1 penalty
• Hospitals in 10th 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

• Americas Health Insurance Plans- AHIP
• Pharmaceutical Research and Marketing
  Association- PhRMA
• AdvaMed
• American Hospital Association- AHA

21
(No Transcript)
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

24
(No Transcript)
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
NSQIP Annual Report Mortality O/E Ratios for All
Operations
Statistically significant high outlier
(inferior performance)
Statistically significant low outlier
(superior performance)
3
2
1
0
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

• 1980s- 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
• NQF
• AQA

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
Surgeons Imperative

• Protect the Interests of the Sick
• Self Interest
• Corporate Interests
• Profit
• Government Interests
• Politics
• Bureauocracy
• Live by the Scientific Method
• Evidence-based Medicine
• Reliable Data
• Recognize the Importance of Systems

44
Thank You