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					Pay for Performance- What
    You Should Know
   Philadelphia Chapter
   American College of
         Philadelphia, PA
       Monday, May 8, 2006
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
        The Message
The Sovereign, Autonomous Medical
Profession failed to adapt to a
capitalistic, market driven, health care
The Government and the Capitalists
control the health care industry
Surgeons must adapt new strategies
Quality and safety are paramount
Federal Government Quality
  Improvement Activities
CMS              AHRQ
– QIO            NQF
– NVHRI          CDC
– Premier HQID   VA
– SCIP           DOD
AQA              PHS
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
CMS Programs
Quality Improvement
Organizations (QIO)
Surgical Care Improvement
Project (SCIP)
        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
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
    Premier Hospital Quality
Incentive Initiative Demonstration
CMS Partnership with Premier Inc., a
nationwide organization of not-for-profit
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
   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.
    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
    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
    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
G 8154- Clinician documented that patient was
not eligible candidate for antibiotic prophylaxis
one hour prior to incision
  Capitalist Control of

Market Forces
Managed Care
Financial Power
Legislative Power
Corporate Control of Healthcare
 America’s Health Insurance Plans-
 Pharmaceutical Research and
 Marketing Association- PhRMA
 American Hospital Association- AHA
ACS Databases
National Cancer Data Base (NCDB)
National Trauma Data Bank (NTDB)
American College of Surgeons
National Surgical Quality
Improvement Program (ACS
So What About
   Pay for
Surgeon Compensation
 in the United States
Free market fee-for-service
Usual and customary fees
Organized regulation by
government and health
insurance industry
1980’s- Customary, prevailing, and reasonable
– 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)
The RBRVS Conversion Factor

 Determined by the government or
 the corporations by methodologies
 that became, for practical purposes,
 Market forces will not directly
 determine the value of physician
 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
Pay for Performance

AMA Consortium
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
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
   ACS Cancer Measures
     Submitted to NQF
Colorectal Cancer
– Resected colon speciman contains at least
  12 regional lymph nodes histologically
– 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
  Measure Specifications-
 Minimum Node Examination
Name of Measure
– Resected colon specimem should have at least
  twelve lymph nodes histologically examined.
– 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
Measure Specifications- Minimal
     Node Examination
Data Elements, Definitions,and Allowable Values
– Surgical Procedure
    Segmental Resection
    Total Colectomy
    Total Proctocolectomy
– Number of Regional Lymph Nodes Pathologically
Data Analysis Logic and Method
Risk- Adjustment Method
Cohort Definition and Sampling Method
Quality Indicators/Value-Based
         Professional Societies
           AMA Consortium



        Health Insurance Industry

          Practicing Physicians
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
Assessment of the Quality of Surgical
  Care: The Surgeon’s Imperative
Protect the Interests of the Sick
 – Self Interest
 – Corporate Interests
 – Government Interests

Live by the Scientific Method
 – Evidence-based Medicine
 – Reliable Data
Recognize the Importance of Systems
Thank You

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