• Health Policy and Government Relations
• Contact Congress - Take Legislative Action
• SVS Health Policy Committee Meets with Senators/Staff
• Priority Issues
• Imaging Cuts
• SAAAVE Act
• Physician Payment
• Pay For Performance (P4P)
• Fistula First Initiative
• Malpractice Reform
• Reimbursement
• Regulatory Issues
• Political Action Committee
• 110th Congress Committee Assignments

Pay For Performance (P4P)

Under congressional pressure, CMS has been hard at work to find ways to reward quality, placing enormous efforts in the P4P concept, also called value-based purchasing. CMS is even promoting its own P4P mottos: "The right care for every patient every time" or "Payment is traditionally determined by what was done to a patient; P4P will allow payment to be determined by what is done for a patient." P4P is not a new concept; in its current form, P4P has been used by businesses to improve quality and efficiency. Various P4P schemes include offering bonuses in addition to regular salary or withholding part of the salary and allowing the employee to earn it back as a reward for increased efficiency, quality, or productivity. Such reward should be of a sufficient value in order to result in the intended change in behavior, and its application should be simple enough to be understood by the employee and to allow ease in implementation and monitoring.⁵ However, P4P may have unintended consequences; for example, if only efficiency is rewarded, quality may suffer. Similarly, in nonmedical fields, good  performance may equate with improved profits, perhaps without emphasis on quality. When P4P models are used in the medical and surgical fields, however, most think of performance in terms of improved quality as represented by improved outcomes.

Very few peer-reviewed publications can be found to support this approach. A recently published article in JAMA that examined data on three performance outcome measures (cervical cancer screening, mammography, and hemoglobin A1c testing) concluded: "Paying clinicians to reach a common, fixed performance target may produce little gain in quality for the money spent and will largely reward those with higher performance at baseline." Those above the target threshold feel that what they need to do is keep the status quo to get the performance bonus. In addition, the authors  speculated that the performance bonus was too modest, at 5% annually, to result in a significant behavior change.⁶ However, despite the absence of appropriate research validating the merits of P4P, the process is not slowing down.

Monitoring the results and outcomes of surgery is not new to this specialty. Surgery has always monitored its results, and its members have long submitted themselves to public critique by peers and colleagues in mortality and morbidity conferences on a weekly or monthly basis. As early as the 1900s, Ernest Codman vigorously championed the idea of reporting results against the opposition of the medical establishment in his State of Massachusetts. In 1908 Codman stated: "Every hospital should follow every patient it treats long enough to determine whether or not the treatment had been successful and then to inquire, if not, why not?" However, Dr Codman's efforts were appreciated and their benefits were realized long after his death.⁷ The concept of hospital standardization, Dr Codman proposed in the ACS clinical congress of 1912, led to the formation of the Joint Commission of Accreditation of Hospitals in 1952, which became the present-day Joint Commission of Accreditation of Healthcare Organizations (JCAHO).⁸

Although surgery has long monitored its own results primarily by using the mortality and morbidity format, cumulative results and outcomes on a surgeon, hospital, state, or national level have not been collected except for those high-visibility key procedures such as cardiac surgery. For over two decades now, there has been a concern that the government has been spending an enormous amount of money on the Medicare and Medicaid programs without an appreciable return on quality. However, what brought this issue to the forefront and increased the awareness of the public to the issue of quality and patient safety are two documents produced by the Institute of Medicine that received enormous levels of publicity. These two documents identified the problem of in-hospital medical errors and attempted to propose solutions for it. To Err is Human, which was published in 2000, estimated that 98,000 patients die annually in American hospitals not as a consequence of their disease, but because of medical errors.⁹ This publication highlighted the importance of improving health care delivery systems. It also called for patients’ involvement in their own care as a protective mechanism to detect and avoid such mistakes. One of the recommendations made to improve patient safety was improving data collection and analysis.

Published a year later, Crossing the Quality Chasm recommended that "all health care organizations, professional groups, and private and public purchasers pursue six major aims; specifically, "health care should be safe, effective, patient-centered, timely, efficient, and equitable." To do so, this document suggested performance expectations for the American health care system aligning the incentives of reimbursement and accountability with improvement of quality targets.¹⁰ Frustrated by the seemingly slow progress of the efforts to institute performance measurement, the Institute of Medicine produced another landmark document in January 2006 entitled Performance Measurement: Accelerating Improvement.¹¹ This report, which was produced by a committee at the Institute of Medicine at the request of Congress, focuses on selecting measures to support quality-improvement efforts. It is the first report in what is known as the Pathways to Quality Health Care series, which will also include payment incentives and quality improvement initiatives. This committee recommended that Congress establish a National Quality Coordination Board funded by the Medicare Trust Fund to oversee the development of performance measures and their implementation.¹²

Surgical Care Improvement Project

For over a decade now,¹³ CMS has been promoting improved quality and efficiency by contracting with Quality Improvement Organizations to monitor and improve quality of health care delivery to Medicare beneficiaries in various states. CMS aimed to demonstrate the effect of incentives on improved quality by partnering with Premier Inc, a nationwide  organization of not-for-profit hospitals. The participation of Premier hospitals in this project was voluntary. This demonstration program was launched on March 13, 2003. Thirty-four quality measures in five acute clinical areas were tested. These areas included acute myocardial infarction, coronary artery bypass graft, heart failure, community-acquired pneumonia, and hip and knee replacement surgery. CMS aimed to reward top-performing hospitals by increasing their payment for Medicare beneficiaries. For the top decile hospitals, the bonus will be 2% of the Diagnosis-Related Group–based prospective payment for the patients in the measured condition for all Medicare fee-for-service beneficiaries. Hospitals in the second decile will be paid a bonus incentive of 1% of the Diagnosis-Related Group–based prospective payment amount. Over 100 Premier hospitals participate in this demonstration project.¹³

Although surgery was not an early focus of CMS efforts in the P4P area, through a steering committee formed by a collaboration of 10 national organizations including the Agency for Healthcare Research and Quality (AHRQ), the ACS, CMS, and the Centers for Disease Control and Prevention, the Surgical Care Improvement Project (SCIP) was born. This project was developed as an extension of the Surgical Infection Prevention program, which aimed to reduce perioperative infection by timely and appropriate use of antibiotic prophylaxis. SCIP is based on the premise that a good number of the complications in over 40 million operations performed annually in the United States can be avoided by appropriate perioperative care. In fact, SCIP’s general aim is to reduce surgical morbidity and mortality by 25% by the year 2010.¹⁴ To do so, SCIP’s specific goals are to reduce the incidence of:

1. Surgical site infection.
2. Perioperative adverse cardiac events.
3. Venous thromboembolic events.
4. Postoperative respiratory complications.

To monitor the implementation of the above goals, specific outcome measures were put in place. For example, to monitor timely and appropriate antibiotic coverage, the following measures were to be implemented:

1. Prophylactic antibiotic received within 1 hour prior to surgical incision.
2. Appropriate prophylactic antibiotic selection for surgical patients.
3. Prophylactic antibiotics discontinued within 24 hours after surgery end time (48 hours for cardiac patients).

Such outcome measures are to be monitored, and institutions that are in compliance will be financially rewarded. Various states' Quality Improvement Organizations contracted with CMS to recruit physicians and hospitals to implement SCIP. Quality Improvement Organizations have also worked on developing data collection systems and test their usability, in addition to providingadministrative support in some instances. However, implementation of a fully mature P4P model is not immediate, and actual P4P will probably be implemented in 4 to 5 years. Until full maturation of the program, voluntary reporting, pay for reporting, and pay for participation will be implemented. CMS hopes that the voluntary and rewarded efforts put in place for
reporting and participation would raise the awareness of health care providers and improve the quality of services delivered to Medicare beneficiaries even before the actual implementation of mature P4P programs years later.

Physician Voluntary Reporting Program

Holding itself to the implementation timeline, CMS announced on October 28, 2005, that it would put in place a Physician Voluntary Reporting Program (PVRP) to start at the beginning of 2006. In the notification it published on November 2, 2005, CMS stated that the PVRP is being rolled out as a part of its overall quality-improvement efforts to "substantially improve the health and function of our beneficiaries by preventing chronic disease complications, avoiding preventable hospitalizations, and improving the quality of care delivered." The notification went on to state that "CMS is committed to the development of reporting and payment systems that will support and reward quality" and that "the quality initiatives aim to . . . ultimately support new payment systems that provide more financial resources to provide better care, rather than simply paying based on the volume of the service."

In order for CMS to implement this program, it used the already established administrative system for physicians' claims. Medicare instituted a group of G-codes (G for government). These codes are reported along with the CPT codes used to describe the service provided. For example, to report whether an AV dialysis access was performed by using autogenous tissue or prosthetic material, two G-codes were approved: G8081 if the access was autogenous and G8082 if it was not. PVRP originally called for data collection on 36 quality measures. However, the number of measures was revised for 2007, to include 45 measures only (see PVRP Quality Measures List). Each measure has a numerator (the number of G-codes reported) and a denominator that is specifically defined for each measure. CMS will calculate the percentage rate for each of the measures reported and feed the data back to providers who volunteer to participate. When this started in April 2006, there was an objection from the AMA against the use of G-codes by CMS to collect and report data since the CPT includes category II codes that are also intended to report quality. CMS considered reporting by G-codes to be an interim step until more robust systems based on data mining from electronic health records are in more widespread use. Indeed, CMS is in the process of developing prototypes for nationwide health information network architecture in an attempt to move the country toward using personal electronic health records. Recently, Mike Leavitt, Department of Health and Human Services Secretary, announced that his department would be awarding $18.6 million in contracts to four groups or consortia of health care and health information technology organizations to develop such prototypes implementing electronic health records that can follow up consumers throughout their lives. Each group is a partnership between technology developers and health care providers. The idea is that each consortium develops a prototype network for secure information sharing among different health care providers to include physicians, hospitals, laboratories, and pharmacies. In addition, the Department of Health and Human Services is prompting all four groups to work together to ensure that information flows seamlessly among the four networks. Once a system that connects all health care markets matures, CMS and other insurers will have a health care data mining capability that can easily monitor the performance of health care providers throughout the United States.¹⁵ See related PVRP article.

AMA/Physician Consortium for Performance Improvement

To develop clinically valid and evidence-based quality measures, the AMA formed the Physician Consortium for Performance Improvement. The Consortium, of which the ACS and the Society for Vascular Surgery (SVS) are two of about 70 member organizations, enlists the expertise of physicians and experts on methodology. Its stated mission is "to improve patient health and safety by: identifying and developing evidence-based clinical performance measures that enhance quality of patient care and that foster accountability; promoting the implementation of effective and relevant clinical performance improvement activities; and advancing the science of clinical performance measurement and improvement." CMS contracts with the Consortium directly or through a third party. Once the proposed performance measures are in place, they are ready to be vetted and endorsed by the National Quality Forum.The Forum, which was incorporated in 1999 in response to the report of the President’s Advisory Commission on Consumer Protection and Quality in Health Care Industry, promotes valid, comparative data needed to improve health care quality.¹⁶ The National Quality Forum is now the organization whose stamp of approval is important to legitimize a performance measure.

Ambulatory Care Quality Alliance and Surgical Quality Alliance

The Ambulatory Care Quality Alliance (AQA) emerged as a key player in CMS’ efforts to enlist the support of various organizations for its performance measures. Many organizations belong to AQA: specialty societies, health care purchasers, health care insurers, government agencies, consumer groups, and other quality care experts. AQA was convened in September of 2004 by four organizations: the American Academy of Family Physicians, the American College of Physicians, America’s Health Insurance Plans, and the AHRQ. The mission of this organization is to "Improve health care quality and patient safety through a collaborative process in which key stakeholders agree on a strategy for measuring performance at the physician level; collecting and aggregating data in the least burdensome way; and reporting meaningful information to consumers, physicians and other stakeholders to inform choices and improve outcomes." Initially, surgery was not well represented in AQA; however, realizing the importance of the issue at hand, the ACS and other surgical organizations, including the SVS, joined the effort.

In its first and invitational meeting held in Washington, DC, on September 8, 2005, over 125 individuals representing about 50 organizations attended the AQA meeting, which was facilitated by Dr Carolyn Clancy, the director of AHRQ. The opening remarks were delivered by Dr Mark McClellan, CMS administrator. This high level representation from CMS and AHRQ, both government agencies under the Department of Health and Human Services, points to the importance this department places on the work of AQA. Staying true to its mission, the work of the AQA was assigned to three major workgroups; performance measurement, data sharing and aggregation, and reporting workgroups. As an indication of the wide representation of the AQA, the reporting workgroup was cochaired by Randy Johnson, the Director of Human Resources Strategic Initiatives of Motorola Corporation, and Dr Nancy Nielson, the Speaker of the House of Delegates of the AMA. This collaboration between a representative from Motorola, a health care purchaser, and the AMA, a health care provider organization, was the idea behind the formation of the AQA.

Concerned that surgery would be marginalized in the deliberations of the AQA, ACS went a step further and formed the Surgical Quality Alliance, hoping to involve all surgical specialties and anesthesia to deal with issues of surgical quality and develop surgery-specific measures. In its first meeting in Washington, DC, on December 5, 2005, the group discussed surgical quality measures to finalize their definitions and G-code assignments. The Surgical Quality Alliance became a very active group; its organizational mission and goals statement highlight its role in bringing surgical specialties together in developing and collating surgical quality measures, disseminating the information on quality initiatives and programs at the federal and private levels, and coordinating the response of the surgical community to such initiatives. AQA also recognized surgery by creating the surgery/procedures work group.

To simplify the current process of developing a performance measure: CMS requests a measure directly or through a third party, and the Consortium writes the measure, which is then vetted and endorsed by the National Quality Forum. The AQA gets consensus buy-in from stakeholders, and then CMS uses the measure for P4P purposes (Fig 2).

Fig 2. A simplified representation of the current process for the development of quality measures. CMS, Centers for Medicare and Medicaid Services; AMA, American Medical Association; NQF, National Quality Forum; AQA, Ambulatory Care Quality Alliance.

Fistula First Breakthrough Initiative

In addition to working on quality measures, CMS is also delving into the development of comprehensive P4P programs. The model for such programs is one of interest to vascular surgeons: increasing the percentage of autogenous AV access procedures performed nationally. Autogenous accesses have better patency and fewer complications; therefore, the higher the rate of autogenous accesses placed, the better renal failure patients will fare and the less the expense will be. Obviously, CMS is interested in both outcomes. With CMS’s encouragement, a wide range of organizations provided representatives to the Fistula First coalition. This performance program outgrew from the Fistula First Initiative, which was launched by CMS in early 2004 in response to the high percentage of prosthetic AV accesses placed nationally and to the variation of this rate in different regions of the United States. The Northwest and New England regions enjoy the highest rates of autogenous accesses, whereas the mid-Atlantic area has been plagued with high rates of prosthetic grafts. With CMS’s encouragement, a wide range of organizations provided representatives to the Fistula First coalition, including representatives from nephrology and surgery, dialysis nurses, dialysis units, hospitals, and corporations, to name a few. The main function of this group was to put together, for CMS consideration, a comprehensive program using financial performance incentives to increase the rate of autogenous access nationally. The stated goals of the effort were to improve the quality of hemodialysis access care by promoting a "safe, effective, patient-centered, timely, efficient, and equitable care provided to individuals with end-stage renal disease." From the very beginning, representatives of vascular surgery played an active role in this group’s deliberations; the Clinical Practice Task Force submitted a proposal suggesting that the financial incentives should be limited in a P4P model to the surgeon performing the procedure and to the dialysis unit that maintains the access, the incentives should be large enough to make a difference, and the data should be adjusted for patient-related factors once the entire program is rolled out. A document was submitted by the Fistula First Coalition to CMS that included some, but not all, of the points suggested by the vascular surgery group.

One important and positive byproduct of the Fistula First program was the introduction of a G-code by CMS to improve the use of autogenous venous tissue for access placement. This code, G0365, is eligible for reimbursement and is intended for duplex ultrasound mapping of the extremity’s venous outflow and arterial inflow.

Carotid Stenting Reimbursement

In its memorandum on carotid stenting, CMS introduced perhaps the first P4P program for a surgical specialty. CMS not only required specific conditions for facility certification, but they also set the exact preoperative conditions and the anatomic degree of disease that have to be met to satisfy their conditions for reimbursement. To maintain credentialing, CMS mandated that either the facility or a contractor to the facility collect, analyze, and submit to CMS, on a 6-monthly basis, data on all carotid artery stenting procedures performed at the facility. The data must be made available upon CMS request; a facility continues be reimbursed for this procedure if it maintains a level of performance acceptable to CMS—in other words, P4P.

Reprinted from Journal of Vascular Surgery, Volume 44, Number 4, October 2006, Anton M. Sidawy, MD, MPH, Washington, D.C., "Pay for Performance: The process and its evolution," 892-902, Copyright 2006, with permission from The Society for Vascular Surgery.

Journal of Vascular Surgery (http://www.jvascsurg.org)