Surgery News - October 2007 - (Page 8)

S U R G E R Y NEWS • O C T O B E R 2 0 0 7 THE 20/20 Quality of Care CABG • VISION Evolutionary Changes in Surgical Practice be for the health system or for the cardiac surgeons and other providers who are at financial risk. Dr. Steele explained that surgeons, nurses, and other providers set their own metrics for pay-for-performance related to ProvenCare. Overall compensation rises if they hit the benchmark. There’s no penalty for failing to hit the “bogey,” Dr. Steele said, referring to the metric. Geisinger will mitigate its risk if it can convince commercial insurers to purchase the ProvenCare program, he said. But to attract that business, the health system has to make the ProvenCare guarantee for more conditions and procedures, he said. Geisinger is already using the same model for angioplasty after acute myocardial infarction, cataract surgery, total hip replacement, medical management of coronary artery disease, and chronic management of diabetes. ProvenCare will also be expanded to ensure proper use of erythropoietin. The savings are more of a lure for insurers and employers than any quality promise, observed Dr. Shabot, an ACS Fellow. Insurers have not been using quality benchmarks as a tool for rate negotiations—yet, he said. Even so, staff members at Memorial Hermann continually try to update—for public consumption on the hospital’s Web site— the information collected for Hospital Compare, a database maintained by the Centers for Medicare and Medicaid Services that theoretically allows consumers to compare hospital performance in managing acute myocardial infarction, congestive heart failure, and pneumonia. According to one study, performance on these measures accurately reflects better outcomes (Health Affairs 2007;26:1104-10). The authors looked at data submitted on the 10 “core measures” in those three conditions from 4,048 acute care hospitals for 20042005. They found that hospitals in the top quartile of performance had 1% lower mortality for acute myocardial infarction, 0.4% lower death rate for congestive heart failure, and 0.8% lower mortality for pneumonia. The measures are a first step toward transparency, Dr. Shabot said, adding that payers “talk about quality, but really what they’re concerned about are their costs.” Dr. Darrell A. Campbell Jr. agreed that payers are not negotiating based on quality of care; instead, they assume that quality is there. Even so, it’s crucial to keep collecting data and to develop measures that will help a hospital or a health system judge a provider’s or a surgeon’s competence, Dr. Campbell, an ACS Fellow and chief of clinical affairs at University of Michigan Health System, Ann Arbor, said in an interview. While surgeons might balk at more transparency, making the data public could change surgeon behavior “because we’re competitive,” he said. The surgical community “recognizes that this kind of accountability is going to come,” said Dr. Campbell. “But what [surgeons] want is a fair system,” one into which they have had a lot of input. ■ from page 1 and 8 checks before and during surgery, including documentation that the patient received the correct dose of β-blocker and preoperative antibiotics within 60 minutes of incision, and that the left internal thoracic artery is used for grafting of the left anterior descending artery. There are 10 postoperative checks, and 6 during the follow-up period. The processes come from guidelines established in 2004 by the American College of Cardiology and the American Heart Association, Dr. Glenn Steele, Jr., CEO of Geisinger Health System, said in an interview. Geisinger surgeons were already using the Society of Thoracic Surgeons’ algorithms for mortality and morbidity risk prediction. ProvenCare was not undertaken as a means of righting a listing ship. Geisinger already did well on many quality scorecards. For instance, its main hospital, Geisinger Medical Center, had a very low mortality rate for CABG, according to a ranking compiled by the Pennsylvania Healthcare Cost Containment Council. ProvenCare’s goal is to “change the reimbursement incentives,” said Dr. Steele, an ACS Fellow. Under the old system, surgeons were rewarded more with escalating costs. With that cost escalation removed, the incentive now is to achieve an expected outcome or best practice standard for an entire episode of care, he said. Surgeons can opt out of a process if it is not appropriate for an individual patient, but that rarely occurs, said Dr. Steele. Another unique aspect of ProvenCare: If anything is missed on the preoperative checklist, the surgery will often—though not always—be postponed. As an integrated health system, Geisinger has an advantage of having physician-employees; in addition, it owns Geisinger Health Plan, an insurance company with 210,000 enrollees. So far, ProvenCare’s CABG flat fee is being offered only to Geisinger Health Plan members, who account for about a third of the system’s patients. The fee is equivalent to half of the historical costs for CABG-related care during the first 90 days after surgery. Outcomes for the first 9 months of the CABG program were presented at the American Surgical Association meeting in April 2007. Overall, mean hospital charges fell 5% and length of stay decreased by 12% for the 81 patients in ProvenCare, compared with 143 patients who received conventional care in 2005. There were no readmissions to the intensive care unit with the new system, no deaths, and no deep sternal wound infections in the 81 patients, compared with four readmissions, two deaths, and one deep sternal wound infection in the conventional care group. While these results bode well for quality of care, it’s not clear what the upside will COMMENTARY: HEALTH POLICY NEEDS OUR HELP surgeon little awareness all of the inAbusyinofcreating,has activitiesand volved monitoring, engage in the dialogue and debate about health policy decisions and their effects on the delivery of surimplementing “health policy.” Yet gical care. We anticipate that the day by day, health policy decisions ACS Institute for Health Policy Reare affecting surgeons’ clinical and search will fill that void. The present election cycle offers a business practices at an increasing rate. Now more than ever, surgeons great opportunity for us to define surgical care and to eduand the organizations cate policy makers and that represent them other health system must understand and stakeholders—such as participate in this arena. employers, health insurHealth policy may be ers, and patient defined as a field of groups—about the need study of specific health for surgical care. The isissues or problems and of sues under debate are governmental responses broad when viewed in to them. It lies at the intersection of health sci- BY LAMAR S. MCGINNIS the context of our current and future national ence, sociology, ecoJR., M.D., FACS health care needs. Instinomics, and politics, and is reflected in the actions taken by tute staff will study and issue stategovernments and in the intentions ments addressing concerns such as resolving across-the-board shortages that determine those actions. In an effort to be an even more of health care professionals, assessactive player in this area, the Amer- ing patient outcomes with an eye toican College of Surgeons is estab- ward quality, changing the present lishing an Institute for Health Poli- “toxic reimbursement system” to a true value-based system, extending cy Research in Washington, D.C. The College first established a health insurance coverage to all, adWashington office in 1979 as part of dressing regional disparities in qualthe Socioeconomic Affairs Depart- ity of care, determining how to dement, which has evolved into the velop more patient-focused systems ACS Division of Advocacy and of care, and moving from a focus on Health Policy. At the outset, the episodic care for the sick to a health Washington office served primarily care system aimed at preventing disas a “listening post” in order to ease and maintaining wellness. The Institute’s work is already unkeep Fellows apprised of the growing federal involvement in surgical derway. We recently entered into a practice matters. Since then, the contract with the Harvard Business College’s resources in Washington School to conduct an in-depth study have increased substantially. A of the surgical workforce. The study Health Policy Steering Committee will look at how changing demowas established in 2001 to address graphics, technology, practice envipolicy priorities and strategies. Sub- ronment, and other factors are afsequently, the College moved to es- fecting the surgical workforce. Change is always with us, but tablish an American College of Surgeons Professional Association major changes in our system of (ACSPA). The Board of Directors health care appear to be on the for the ACSPA political action com- horizon. The availability and analymittee advises this organization on sis of high-quality data and the oppolitical activities. The Division of portunity to publish, present, and Advocacy and Health Policy has 17 represent the findings drawn from staff members, 14 of whom are in this information will enable the ColWashington, and all are vigorously lege to ensure that surgical patients engaged in federal legislative and are better served in the future. regulatory affairs and in state affairs. Health policy matters will deterThe surgical specialty societies mine our future, so informed indihave been devoting greater re- vidual and organizational particisources to health policy activities in pation is critical. Washington as well. However, the surgical specialties have lacked the DR. MCGINNIS is a clinical professor sophisticated data collection and of surgery at Emory University, analysis resources necessary to Atlanta, and vice chair of the meet the ever-growing needs of American College of Surgeons Health staff and members seeking to fully Policy Steering Committee.

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Surgery News - October 2007

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