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 EducationMy CFO’s Perspective

• 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”

© Copyright. All Rights Reserved. Cost of Care. 3

• 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).

Value-Based Residency Training and Reimbursement:

CMMI Project Proposal

PI: Joel Katz MDHypothesis: 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....

Global Capitation

Fee for Service

P4PMedical Home

Bundled Payments

Adapted from Dr. James Mongan presentation 5/26/2009

Level of financial risk borne by provider

Level of financial risk borne by payor

...but all models involve performance measurement and accountability

Bundled ProceduresSurgeon-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

7

MD Cases CMI Total OR

TimeTeam 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

Average Direct Cost per Inpatient DischargeTotal Knee Replacement - OR Related Costs - FY11

Surgeon-specific Metrics

The Next Generation?

Porter ME.NEJM 2012

QPID Appropriate Procedure Order

: Evidence Based Guidelines

>50% Stenosis as determined by ultrasound or angiogram and symptomatic

Print Personalized Consent

Schedule Surgery

>80% Stenosis as determined by ultrasound or angiogram and asymptomatic

Patient has received a decision aid

Complex case (write exception below)

Risk Calculator:

If guideline criteria not met, but patient still requires surgery, add justification here

Procedure Decision Support

Carotid Stenosis

Risk of Mortality 1.6%Morbidity or Mortality 17.0%Long Length of Stay 7.7%Short Length of Stay 38.4%Permanent Stroke 1.1%Prolonged Ventilation 8.2%DSW Infection 0.4%Renal Failure 7.6%Reoperation 6.7%

Print Personalized

ConsentSchedule Surgery

Carotid Stenosis Therapy

Step 1: Indications with exceptions

Step 2: Perioperative risk assessment

Step 3: Shared decision making

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 appropriatenesseg. 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. BerraY. Berra