Transcript Intersection of Surgical Outcomes and Medical Education A CMO’s Perspective • How can I get housestaff to think about value-based clinical medicine using outcomes data? •

Intersection of Surgical
Outcomes and Medical
Education
A CMO’s Perspective
• How can I get housestaff to think about value-based
clinical medicine using outcomes data?
• Can outcomes data be used to incorporate a culture of
quality improvement into surgical training?
Medical Education
My CFO’s Perspective
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Declining hospital margins
Inefficiencies in the care model
Declining GME funds
Growing emphasis on education over service
Time away for didactics, simulation
“Explain to me again why I would rather pay for a
resident than a PA or NP”
• Congress should authorize the Secretary to change Medicare’s
funding of graduate medical education (GME) to support the
workforce skills needed in a delivery system that reduces cost
growth while maintaining or improving quality.
• The indirect medical education (IME) payments above the
empirically justified amount should be removed from the IME
adjustment and that sum would be used to fund the new
performance-based GME program. To allow time for the
development of standards, the new performance-based GME program
should begin in three years (October 2013).
© Copyright. All Rights Reserved. Cost of Care.
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Value-Based Residency Training
and Reimbursement:
CMMI Project Proposal
PI: Joel Katz MD
Hypothesis: A new model of hospital
reimbursement can improve:
1) Metrics of health status among patients
cared for by trainees
2) Attainment and utilization of
competencies directly related to value
(quality per unit cost) and lead to more
cost-efficient investments in physicians
in training
Direction Of Health Reform Is Uncertain....
...but all models involve performance measurement and accountability
Fee for
Service
P4P
Medical
Home
Bundled
Payments
Global
Capitation
Level of financial risk borne by payor
Level of financial risk borne by provider
Adapted from Dr. James Mongan presentation 5/26/2009
Bundled Procedures
Surgeon-specific Metrics
• M&M
• LOS
• Readmission rates
• Use of home care, PT, SNF, rehab
• Cost data
• Access
• Patient satisfaction
• Compliance with standardized
pathway
• Site of care
Procedure Cost Assessment
Average Direct Cost per Inpatient Discharge
Total Knee Replacement - OR Related Costs - FY11
MD
Cases
CMI
Total
OR
Time
Team
Supplies
Implants
Recovery
Pharm
Rad
Other
A
237
3.63
$7,572
$1,029
$2,652
$2,779
$1,113
$6
$18
$1,204
B
91
3.85
$8,965
$1,715
$3,086
$3,025
$1,140
$29
$39
$1,522
C
90
4.37
$10,392
$1,668
$4,106
$3,455
$1,163
$11
$46
$1,508
D
76
3.96
$8,661
$1,498
$2,550
$3,625
$988
$6
$80
$1,423
E
56
3.7
$8,084
$1,265
$2,680
$2,920
$1,219
$6
$76
$1,251
F
46
3.82
$11,457
$1,838
$2,570
$5,821
$1,228
$22
$360
$1,800
G
29
3.97
$8,822
$1,802
$2,789
$3,210
$1,022
$4
$43
$1,545
H
26
3.78
$11,543
$1,490
$3,514
$5,456
$1,082
$10
$229
$1,462
I
19
3.53
$8,047
$1,498
$2,319
$3,269
$961
$206
$16
$1,312
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Surgeon-specific Metrics
The Next Generation?
Porter ME.
NEJM
2012
Procedure Decision Support
Carotid Stenosis
QPID Appropriate Procedure Order
Carotid Stenosis Therapy
: Evidence Based Guidelines
>50% Stenosis as determined by ultrasound or angiogram and
symptomatic
>80% Stenosis as determined by ultrasound or angiogram and
asymptomatic
Complex case (write exception below)
Patient has received a decision aid
Print Personalized Consent
Schedule Surgery
Step 1: Indications with
exceptions
Step 3: Shared decision
making
Risk Calculator:
Risk of Mortality1.6%
Morbidity or Mortality
Long Length of Stay
Short Length of Stay
Permanent Stroke
Prolonged Ventilation
DSW Infection 0.4%
Renal Failure 7.6%
Reoperation
17.0%
7.7%
38.4%
1.1%
8.2%
Step 2: Perioperative risk
assessment
6.7%
Print
Personalized
If
guideline
criteria not met, but
Schedule Surgery
Consent
patient still requires surgery, add
justification here
Step 4: Outputs
CPIP: Clinical Process Improvement Leadership Program
How do we prepare our
residents for what’s coming?
• Make outcomes analysis routine
• Give them the tools to improve
eg. CPIP, Lean, Toyota
• Emphasize appropriateness
eg. clinic, advanced care planning, palliative
care
• Teach them some finance analysis and
accounting
• Team training and leadership skills
• Patient experience training
The future ain’t what it used to be.
Y.Y.Berra
Berra