Pay for Performance:Pay for Performance:Meaningful Metrics and Meaningful Metrics and

Measures from the Measures from the Program Director’s Program Director’s

PerspectivePerspectiveGeorge M. Fuhrman MDGeorge M. Fuhrman MD

Program Director Surgery Atlanta Program Director Surgery Atlanta Medical CenterMedical CenterAPDS PanelAPDS Panel

March 25, 2011March 25, 2011

DisclosureDisclosure Knew nothing about this topic one Knew nothing about this topic one

month agomonth ago Appreciate the opportunity to Appreciate the opportunity to

participateparticipate Little scientific evidence – formed a Little scientific evidence – formed a

personal opinion based on my readingpersonal opinion based on my reading Apologize to those I offendApologize to those I offend I am a little bit scared of the futureI am a little bit scared of the future

OverviewOverview Metrics from the Program Director’s Metrics from the Program Director’s

PerspectivePerspective Metrics from MedPac’s perspectiveMetrics from MedPac’s perspective Problems with P4PProblems with P4P

Lessons from industryLessons from industry Lesson from Delivery of Clinical CareLesson from Delivery of Clinical Care

Strategies in anticipation of changeStrategies in anticipation of change

Pay for Performance:Pay for Performance:Meaningful Metrics and Meaningful Metrics and

measures from the Program measures from the Program Director’s PerspectiveDirector’s Perspective

P4P is a strategy that potentially can P4P is a strategy that potentially can accomplish one of two goalsaccomplish one of two goals

Financially incentivize productive Financially incentivize productive work – be prepared to grow the work – be prepared to grow the prizeprize

Contain costs –Fix the size of the Contain costs –Fix the size of the prize and redistributeprize and redistribute

P4P – Metrics we understandP4P – Metrics we understand

Resident RecruitmentResident Recruitment ABSITE Scores – high stakes exam!!!!ABSITE Scores – high stakes exam!!!! Resident Faculty and Other Evaluations Resident Faculty and Other Evaluations

of Program – 360 degree assessmentof Program – 360 degree assessment Is your program taking up a Is your program taking up a

disproportionate amount of GMEC time?disproportionate amount of GMEC time? Accreditation CitationsAccreditation Citations Technical SkillsTechnical Skills Fellowship and Job PlacementFellowship and Job Placement ABS QE/CE PerformanceABS QE/CE Performance

MedPac MedPac PerspectivePerspective

Our GME system is the best in the Our GME system is the best in the worldworld

HOWEVER – we are not producing HOWEVER – we are not producing physicians needed for a 21physicians needed for a 21stst century century health care delivery system focused health care delivery system focused on quality, value, and affordabilityon quality, value, and affordability

MedPac MedPac PerspectivePerspective

Capable of delivering high quality, high Capable of delivering high quality, high value, and efficiently delivered servicesvalue, and efficiently delivered services

Socioeconomically diverse Socioeconomically diverse Non-specializedNon-specialized Skilled in evidence-based medicine, Skilled in evidence-based medicine,

team based care, care coordination, team based care, care coordination, and shared decision makingand shared decision making

Shift from independent and Shift from independent and autonomous practice to a more patient-autonomous practice to a more patient-centered, team based carecentered, team based care

Important Metrics Important Metrics according to MedPacaccording to MedPac

Skills essential for delivery system Skills essential for delivery system reformreform

Quality measurement and improvementQuality measurement and improvement Evidence based medicineEvidence based medicine Multidisciplinary teamworkMultidisciplinary teamwork Care coordination across settingsCare coordination across settings Health information technologyHealth information technology Utilize the Metrics used to measure the Utilize the Metrics used to measure the

core competencies - Milestones Projectcore competencies - Milestones Project

How many angels can dance How many angels can dance on the head of a pin?on the head of a pin?

Medicare should NOT presume to Medicare should NOT presume to prescribe curricular content or prescribe curricular content or

teaching methodteaching method Accrediting organizationsAccrediting organizations Certifying boards Certifying boards Government advisory boardsGovernment advisory boards Teaching institutionsTeaching institutions Leading health care delivery systemsLeading health care delivery systems InsurersInsurers PurchasersPurchasers PatientsPatients Residency program directorsResidency program directors

Unintended ConsequencesUnintended ConsequencesHewlett-Packard exampleHewlett-Packard example

Pay for performance was INITIALLY successful Pay for performance was INITIALLY successful production increasedproduction increased

High performing production teams refused to High performing production teams refused to admit new members perceived to be below admit new members perceived to be below their level of expertisetheir level of expertise

Underperforming groups (e.g. parts delivery) Underperforming groups (e.g. parts delivery) impacted production causing resentment and impacted production causing resentment and financial difficulty for employees unable to financial difficulty for employees unable to maintain new higher standards associated with maintain new higher standards associated with increased payincreased pay

Managers spent all of their time reengineering Managers spent all of their time reengineering pay systems neglecting primary responsibility pay systems neglecting primary responsibility of building trust and company commitmentof building trust and company commitment

Unintended Unintended ConsequencesConsequences

Too focused on metricsToo focused on metrics - passover - passover marginal US grad for >95marginal US grad for >95thth percentile percentile USMLE international grad?USMLE international grad?

Too exam focused miss out on technical and Too exam focused miss out on technical and communication skills (unless graded)communication skills (unless graded)

Personal tragedy impacts meeting resident Personal tragedy impacts meeting resident ability to meet targets metrics?ability to meet targets metrics?

Does the resident that miscarries or Does the resident that miscarries or divorces jeopardize their training?divorces jeopardize their training?

Threaten the satisfaction that accompanies Threaten the satisfaction that accompanies helping a resident through a tough patch?helping a resident through a tough patch?

Risk AdjustmentRisk Adjustment 2009 APDS keynote speaker Senator 2009 APDS keynote speaker Senator

Bennett boasted about 1/3 cost to Bennett boasted about 1/3 cost to Medicare for providing cardiac care Medicare for providing cardiac care in Salt Lake compared to Miamiin Salt Lake compared to Miami

Our membership pointed out the Our membership pointed out the patient population was not he same patient population was not he same so costs were also differentso costs were also different

Risk AdjustmentRisk Adjustment

MiamiMiami

Salt Lake CitySalt Lake City

Risk AdjustmentRisk Adjustment More headway can be made trying to More headway can be made trying to

assess an individual physician’s or assess an individual physician’s or hospital’s outcome-based average hospital’s outcome-based average performance for a a number of performance for a a number of patients, with statistical control for patients, with statistical control for socioeconomic and health statussocioeconomic and health status

The science of outcome The science of outcome measurements has yet to scale many measurements has yet to scale many methodological hurdlesmethodological hurdlesUwe Reinhardt economics professor Princeton

NY Times October 15, 2010

EmoryEmory

MorehouseMorehouse

Atlanta Medical CenterAtlanta Medical Center

Before we begin to evaluate Before we begin to evaluate performance we must performance we must

define our paydefine our pay Does your contract spell out the portion of Does your contract spell out the portion of

compensation that is education derived?compensation that is education derived? We won’t get to decide on the metricsWe won’t get to decide on the metrics Just like a CABG in Salt Lake City is Just like a CABG in Salt Lake City is

different (risk adjustment) when different (risk adjustment) when compared to Miami training surgeons is compared to Miami training surgeons is different across regions and venuesdifferent across regions and venues

Define our performance at point zero and Define our performance at point zero and evaluate us on our ability to move the barevaluate us on our ability to move the bar

Program Directors do not Program Directors do not set policyset policy

Instead we are forced to adapt and adjust with Instead we are forced to adapt and adjust with limited resources – third world surgerylimited resources – third world surgery

P4P might be our next duty hour situationP4P might be our next duty hour situation We can craft all of the eloquent responses in We can craft all of the eloquent responses in

the world that will fall on deaf ears but if we the world that will fall on deaf ears but if we get the word from above that P4P is here we get the word from above that P4P is here we adjust or struggleadjust or struggle

We should try and get a meaningful seat at the We should try and get a meaningful seat at the table because our future and salaries will table because our future and salaries will depend on it – we should be part of the solution depend on it – we should be part of the solution to solve the problemto solve the problem

IOMMEDPA

CCongress

ConclusionsConclusions The pie is not going to grow – P4P at best will The pie is not going to grow – P4P at best will

be revenue neutral. Gamesmanship (ability to be revenue neutral. Gamesmanship (ability to create and quantify nebulous metrics) will be create and quantify nebulous metrics) will be rewarded at the expense of the ill preparedrewarded at the expense of the ill prepared

Define your pay - if the education portion Define your pay - if the education portion becomes threatened protect the remainderbecomes threatened protect the remainder

Don’t let unintended consequences distract Don’t let unintended consequences distract you from your primary responsibility to take you from your primary responsibility to take care of and educate your residentscare of and educate your residents

We need a seat at the table when policy is We need a seat at the table when policy is formed – hope to influence, if not, we can be formed – hope to influence, if not, we can be informedinformed

SisyphusSisyphus

Duty Hours

P4P

BLOW UP BLOW UP THETHE

DAMN DAMN MOUNTAINMOUNTAIN