Pay for Performance Is Here to Stay

By Mark S. Lesney

Pay for performance is no longer a debatable issue but an inevitability, according to Dr. Anton N. Sidawy, chief of surgical services at the VA Medical Center and professor of surgery at George Washington and Georgetown universities, Washington.

He spoke to the issue in his presidential address at the Society of Clinical Vascular Surgery (SCVS) annual meeting in Las Vegas.

"Although implementation of a fully mature, national pay-for-performance model is running on a timeline that currently puts it around the year 2010, the Centers for Medicare and Medicaid Services (CMS) created the Physician Voluntary Reporting Program starting in January of this year, with pay for reporting probably starting in 2007," he said.

The reporting program and other such quality initiatives aim to "ultimately support new payment systems that provide better care, rather than simply paying based on the volume of service," said Dr. Sidawy, quoting from the CMS notification.

Performance measures are being implemented by CMS and various players in the health care system to measure quality of care. Currently, the process of developing a performance measure includes the following steps, according to Dr. Sidawy.

First, CMS requests a measure directly or through a third party. Then the American Medical Association's Physician Consortium for Performance Improvement (an umbrella group comprising about 70 member organizations dedicated to developing clinically valid and evidence-based quality measures) writes the measure, which is next vetted and endorsed by the National Quality Forum (a private, not-for-profit organization whose membership encompasses wide representation of the health care system).

Finally, the Ambulatory Care Quality Alliance (AQA) works to get consensus buy-in from stakeholders. With such consensus, CMS can more effectively implement the performance measures. The AQA unites many organizations, including specialty societies, health care purchasers, health care insurers, government agencies, consumer groups, and other quality care experts.

The American College of Surgeons, which was concerned that surgery might be an underrepresented specialty in the deliberations of the AQA, recently formed the Surgical Quality Alliance (SQA), in the hope of involving all surgical specialties and anesthesia in dealing with issues of surgical quality and developing surgery-specific performance measures. Dr. Sidawy said the first meeting of the SQA in Washington, on Dec. 5, 2005, addressed 16 surgical quality measures to finalize their definitions and their G-code assignments.

CMS intends to use G-codes to help in the implementation, collection, analysis, and reporting of various performance measures. G-codes will be used in conjunction with the already established administrative system for physicians' claims. For example, to differentiate between two types of arteriovenous (AV) dialysis access, two G-codes were approved: G8081 to report AV access performed using autogenous venous tissue, and G8082 for access performed using prosthetic material. CMS will calculate the percentage rate for each of the measures reported and feed the data back to providers who volunteer to participate, a process slated to begin in mid-2006. These codes are reported along with the CPT codes used to describe the services provided and are an interim step until more robust reporting systems based on electronic health records reach more widespread use, Dr. Sidawy added.

Although surgery was not an early focus of CMS efforts in promoting improved quality and efficiency, a steering committee formed by a collaboration of 10 national organizations, including the Agency for Healthcare Research and Quality, the American College of Surgeons, CMS, and the Centers for Disease Control and Prevention, created the Surgical Care Improvement Project (SCIP).

"SCIP's aim is to reduce surgical morbidity and mortality by 25% within 5 years by promoting appropriate perioperative care. Specific outcome measures were put in place to be monitored, and institutions in compliance will be financially rewarded," said Dr. Sidawy.

One of the health care system's weaknesses is the unavailability in the private sector of national databases for data collection, risk adjustment, and reporting. In this regard, the Department of Veterans Affairs (VA) health care system has taken the lead in establishing the premier National Surgical Quality Improvement Program (NSQIP) in the nation. NSQIP is the first and continues to be the only noncardiac, national, risk-adjusted, validated, peer-controlled, and outcome-based system.

"Since [NSQIP's] inception in 1991 and until 2002, the 30-day incidence of mortality decreased by 27% and morbidity by 45% in participating VA medical centers," reported Shukri Khuri, one of the founders of this program. Medical centers that are consistently high outliers in morbidity or mortality are asked to review specific areas of concern or are visited by a team that analyzes their programs and offers suggestions for change, he said.

"Impressed by these results, CMS has become very interested in adapting NSQIP to the private sector, and NSQIP will likely become the platform for upcoming CMS pay- for-performance initiatives," Dr. Sidawy said.

The vascular community is working to become a key player in this new arena, said Dr. Sidawy.

The Outcomes Committee of the SVS is working with ACS to develop a carotid stenting and carotid endarterectomy (CEA) modular database based on the NSQIP platform. This would be an outcome-adjusted database that dovetails with the current SVS carotid stenting and endarterectomy registry rolled out by SVS last year. The registry is designed to comply with the new CMS payment requirements and to collect long-term data on carotid stenting and CEA. The program requires specific conditions for facility certification and sets the exact preoperative conditions and the anatomical degree of disease that must be met for reimbursement.

A facility can get reimbursed only if it maintains an acceptable level of performance according to CMS standards. In other words--pay for performance, said Dr. Sidawy.

The issue of funding pay-for-performance programs has not yet been settled. Although all discussions indicate the future appropriation of additional funding to pay for this program, resources have still to be allocated by Congress. Indeed, CMS has rolled out the new Physician Voluntary Reporting Program with no additional funding or financial incentives provided. Physician groups are concerned that this, in effect, risks passing the costs down to the providers. However, beyond the question of financing, Dr. Sidawy says, there are several important issues of concern while pay for performance is being developed and implemented. Such concerns are still not being addressed.

First, there is a lack of high-level evidence that could be used as a foundation for new performance measures. Second, current performance measures for the majority of surgical and vascular procedures lack testing and validation. In addition, too little attention is being paid to developing process measurements and methods that can assess the complete surgical experience and the full continuum of patient care as opposed to just short-term outcomes, he said.

The vascular community should not sit back and wait, even though implementation of a comprehensive program may be 5 years away. "If we don't get engaged in the process now, we won't be able to catch up later," Dr. Sidawy said. "It is much preferable to be actively involved in the process, to help develop the best possible pay-for-performance system for our patients and our specialty."

Pay for performance is here to stay, according to Dr. Sidawy. "No type of practice will be immune, as Congress, insurance companies, health care purchasers, and consumer advocacy groups, such as AARP, are all highly interested in seeing pay-for-performance programs expand and mature. They see it as an opportunity to improve quality and curtail costs. We need to be a part of it."