Strategies for Improving Surgical Quality — Should Payers Reward Excellence or Effort?
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《新英格兰医药杂志》
Along with many other stakeholders, payers are taking an increasingly active interest in the quality of health care. Simple but effective therapies related to disease prevention, screening, and hospital-based medical care are often substantially underused.1,2,3 As incentives, payers have implemented a wide range of pay-for-performance programs that reward physicians (or health plans) financially for high rates of compliance with evidence-based guidelines for care (e.g., appropriate use of screening mammography).4 In the area of surgery, the wide variation in performance by both hospitals and surgeons suggests similar opportunities for payers to encourage improvements in quality.5,6,7,8,9
With regard to surgery, however, payers may need to consider different strategies to bring about improvements in quality. The quality of health care may be assessed on the basis of structure (the attributes of the setting of care), process (the details of the care provided), or outcomes (the results of care).10 In medicine, there is a relatively long list of evidence-based process measures that can readily be acted on and may be used to evaluate the quality of care. Similar process measures are generally lacking for surgery. The use of outcomes to evaluate the quality of surgical care implies the need for detailed clinical data for risk adjustment. Even if such data were widely available, outcome measures are probably less responsive to financial incentives than process measures. For example, a surgeon can immediately increase compliance with guidelines for thromboembolism prophylaxis but may not know how to reduce the risk-adjusted mortality for a given procedure.
For these reasons, payers are exploring strategies beyond pay-for-performance programs (Table 1). Some payers are reexamining centers-of-excellence strategies aimed at directing patients to hospitals that are likely to provide the best results with respect to a particular condition or procedure. Other payers are experimenting with a new, more collaborative model — called "pay for participation" — in the hope of effecting improvements in quality by underwriting the costs of clinical-outcome registries and improvement activities on the part of providers.
Table 1. Strategies to Improve Surgical Care.
In this article, we review ongoing efforts by payers to improve the quality of surgical care through these three approaches. We examine the primary strengths and weaknesses of these approaches and close with suggestions of how payers can most effectively achieve improvements in the quality of surgical care. Many would use the term "payer" more narrowly, but here we use it to mean the broad group of employers, purchasers, insurers, and health care plans that directly or indirectly pay for health care services.
Centers of Excellence
Although the term "centers of excellence" is used in many different contexts, we use it to describe programs aimed primarily at identifying hospitals that are likely to have the best results with respect to selected procedures and at directing patients to these facilities. There are many mechanisms for achieving an increase in the number of patients directed to certain facilities. Payers can use selective contracting — restricting payment for selected procedures to a small number of high-quality hospitals or surgeons. Alternatively, payers can try to persuade patients — by means of tiered health care plans and benefits packages that offer patients financial incentives (e.g., lower copayments or monthly premiums) — to choose selected high-quality providers. Patients can also be encouraged to choose their own providers (self-referral) on the basis of public reporting of information about providers in their geographic area with regard to the volume of procedures, process of care, or direct outcome measures.
Among current examples of centers-of-excellence programs, the Leapfrog Group, a large coalition of public and private employers and purchasers, is promoting "evidence-based hospital referral" for five surgical procedures, using as criteria a minimum procedure volume, selected process measures, and (for cardiac procedures) risk-adjusted mortality rates.11,12 In addition, many payers are implementing their own centers-of-excellence programs for cardiac surgery and other selected procedures. Given the skyrocketing rates of procedures and concern about the uneven quality of procedures, bariatric surgery has recently become a popular target for quality-based selective contracting.13
The centers-of-excellence model has several attractive features. Since these programs rely primarily on volume and other structural measures of quality, they can be implemented quickly and inexpensively. Recent reports suggest that a hospital's history of volume of procedures and mortality rates is a strong predictor of its performance in the future.14,15 Such data imply that many lives could be saved if selected procedures could be concentrated within hospitals that meet certain criteria.12,16
Although current indicators of quality can reliably identify groups of providers that have, on average, better results, these indicators do not reliably discriminate with respect to performance among individual hospitals or surgeons. The limitations of the use of procedure volume as an indicator of quality have been well characterized.17,18 Because of limited sample size, direct outcome measures (e.g., morbidity and mortality) are similarly flawed indicators of a hospital's true performance with respect to most procedures.19 Direct outcome measures are also limited by a lack of readily available clinical data to ensure adequate risk adjustment. Centers-of-excellence programs based on measures that do not reliably reflect provider-specific performance will continue to be viewed as unfair by both hospitals and surgeons and will be strongly opposed.
The centers-of-excellence model is also limited by a lack of reliable mechanisms for redistributing surgical patients. Given the fragmentary state of health care financing in the United States, even well-organized blocs of payers lack sufficient market share and negotiating power with hospitals to dictate surgical-referral patterns.20,21 Public payers, particularly the Centers for Medicare and Medicaid Services (CMS), may have the leverage, but they do not have the political will to take on hospitals and surgeons in order to implement selective-contracting initiatives. Efforts that rely on patients to "shop for quality" may face less resistance, but they are not likely to be very effective. Although stronger financial incentives than are now available may ultimately direct more patients toward centers of excellence, there is little evidence to date that public reporting of data on surgical performance has a substantial effect on patients' decisions or hospitals' caseloads.22,23
Pay for Performance
Rather than direct more patients in need of surgical care to the best hospitals or surgeons, pay-for-performance programs are aimed at encouraging improvements in quality in all settings. In contrast to centers-of-excellence programs, in which rewards take the form of increases in the volume of patients, pay-for-performance programs reward superior surgical quality with direct financial bonuses.
A growing number of payers are implementing pay-for-performance programs in surgery. In a demonstration project begun in 2004, the CMS will pay a reimbursement premium of up to 2 percent to hospitals scoring in the top 20 percent (calculated on the basis of a composite of process and outcome measures) for coronary-artery bypass surgery and surgery for hip or knee replacement.24 By year 3 of the project, hospitals with the worst performance record will be penalized financially.24 The Surgical Care Improvement Project, which was jointly initiated by the CMS and the Centers for Disease Control and Prevention, is promoting several evidence-based processes for the purpose of pay for performance. One of these processes — the timely and appropriate use of perioperative antibiotic drugs — has already been adopted in pay-for-performance plans by Blue Cross and Blue Shield (BCBS) and other large private payers.25 Similar initiatives aimed at preventing postoperative cardiac events, venous thromboembolism, and respiratory complications have also been launched.26,27
Although empirical data establishing the effectiveness of this approach, as compared with others, are lacking, pay-for-performance programs have the potential to achieve rapid and substantial improvements in many aspects of clinical care. At the University of Michigan Hospital, for example, the proportion of patients undergoing colorectal surgery who receive an appropriate antibiotic within 60 minutes before the incision increased virtually overnight, from about 70 percent to more than 95 percent, after the implementation of a pay-for-performance program by one of the hospital's major private payers. Similar improvements might be expected for other aspects of surgical care.
As is the case in the centers-of-excellence model, pay for performance is hindered by a lack of good measures with which to assess the performance of hospitals or surgeons. As already mentioned, provider-specific outcome measures are limited by constraints on sample size and a paucity of sources of the clinical data needed to ensure adequate risk adjustment.19 Despite their predominance in pay-for-performance plans involving primary care, process-of-care measures are less useful indicators of the quality of surgical care. Most such measures are related to aspects of general perioperative care and secondary outcomes (e.g., use of antibiotics to reduce rates of infections at the surgical site). Although these measures may reflect low-hanging fruit, it is not clear that improvements in these aspects of perioperative care would reduce the observed variations in even more important outcomes (e.g., mortality) among hospitals and surgeons. For most procedures, high-leverage processes of care, particularly those specific to a particular surgical procedure, have yet to be identified.
Pay for Participation
The newest strategy for payer-led improvements in surgical quality is pay for participation. According to this model, payers provide the infrastructure and resources for hospitals and surgeons to collaborate with one another to evaluate and improve the quality of surgical care. Hospitals and surgeons are compensated simply for their participation in these collaborative activities, not for individual performance or for the extent of their improvement over time. Instead, effectiveness is judged in terms of collective improvements in morbidity, mortality, and costs.
Pay-for-participation programs have two essential components. The first component is high-quality clinical-outcomes data, which include procedure-specific information on patient characteristics required for risk adjustment, processes of care, and relevant outcomes. The content of the clinical-data registry may be specifically developed for this purpose or may have been developed previously (e.g., the Society of Thoracic Surgeons database is being used in one of the Michigan pay-for-participation programs). Either way, the data are collected prospectively by trained data abstracters, with the use of standardized definitions, and are audited externally for accuracy and completeness.
To achieve improvements in surgical quality in the pay-for-participation model, at regular intervals surgeons and hospitals receive timely feedback on their performance relative to that of their peers. At meetings at regular intervals, surgeons and program coordinators review the performance data on the surgeons and hospitals and the analyses linking specific processes to outcomes. Participants develop plans for specific interventions to achieve improvements, which, under the direction of program coordinators, are implemented at all hospitals. These interventions are later evaluated empirically, discussed at follow-up meetings, and refined.
Although such efforts are now in the early stages of development in other states, in Michigan programs funded and developed by Blue Cross and Blue Shield of Michigan and Blue Care Network (BCBSM) may become the prototypes for pay-for-participation programs in surgery.28,29 Patterned on an established program in interventional cardiology,30,31,32 there are now three separate initiatives targeting cardiac surgery, bariatric surgery, and other general and vascular surgery that include more than 20 of the largest hospitals in the state. Although the programs in Michigan vary in their details,29 in each case hospitals are compensated for data collection and participation in improvement activities in the form of supplements to reimbursements according to the diagnosis-related group for surgical care.
Surgeons' acceptance of this approach is one of the major advantages of pay-for-participation programs. In most current programs, performance data are not publicly reported (and are not shared even with the underwriting payer), and thus, there are no winners or losers. This approach also has the potential to be very effective in improving surgical quality. Previous regional collaborations for improving surgical quality, although most of them were not funded by payers, markedly improved surgical outcomes in cardiac surgery and surgery for rectal cancer.6,7,33,34 A pay-for-participation program in interventional cardiology has also been effective,31 showing significant improvement in providers' adherence to evidence-based best practices. Patients' outcomes have also improved, as reflected by statewide reductions in mortality, unplanned coronary-artery bypass surgery, myocardial infarctions, nephropathy induced by the administration of contrast medium, and stroke after percutaneous coronary interventions.31
Pay-for-participation plans are difficult to organize. Hospitals and surgeons are more accustomed to competing against one another than to collaborating. They also have no direct financial incentives to take part in such plans. Payers cover the costs of data collection and quality-improvement activities, but no one profits financially from pay-for-participation programs. Finally, hospitals and surgeons tend to distrust the motives of payers and worry that pay for participation is just a pretext for collecting data that will ultimately be used for the purposes of selective contracting, public reporting, or both.
Motivating payers to participate may be equally challenging. Although in Michigan one payer (BCBSM) has a dominant market share, in most other regions there are numerous payers, each covering a relatively small proportion of the market. Providers, like payers, have few precedents for collaborating with one another to achieve quality improvement. Pay-for-participation plans are also very expensive. In Michigan alone, the three pay-for-participation programs in surgery combined cost approximately $5 million a year. Most payers will need to be convinced of the business case for quality — that their investment will be returned in the form of reductions in the morbidity, mortality, and costs associated with surgical complications.
Finally, the lack of public reporting in current pay-for-participation initiatives may limit support for these programs. In the context of quality improvement, the value of public reporting is hotly debated.35,36,37,38,39 Proponents argue that public reporting provides a necessary accountability and stimulates rapid improvement.40,41,42 They also cite the moral argument that patients have a basic right to know about differences in outcomes among providers and that such information is central to informed consent.43,44 Opponents counter that public reporting induces gaming and other unwanted behavior among providers (e.g., surgeons' avoiding high-risk patients) and deters physicians from collaborating in the measurement of the quality of care and in improvement activities.45,46,47 On the basis of our observations in Michigan, public reporting was a "deal breaker" for many hospitals and surgeons who were invited to collaborate in the BCBSM programs. In the future, evidence that pay-for-participation programs reduce variation in providers' performance may help to diminish the pressure for public reporting. Alternatively, surgeons and hospitals participating in these programs may grow less defensive about the reporting of data on their performance and relax their opposition to public disclosure.43,44,48,49
Conclusions
Although the different strategies by which payers can leverage improvements in quality each have distinct strengths and weaknesses, the boundaries of the three models are not always as distinct as implied in this review. For example, centers-of-excellence programs may be mainly about directing more patients to the best facilities, but they may also motivate improvement more broadly to the extent that hospitals and surgeons try harder to be the "best." Similarly, the primary goal of pay-for-performance programs may be broad-based quality improvements, but programs that include public reporting may also help to steer surgical patients to hospitals that have the best performance.
Although this article focuses on programs initiated by payers, other groups have their own strategies for effecting improvements in the quality of surgical care. For example, in several states the departments of health have implemented successful public-reporting initiatives in cardiac surgery.6,50 The American College of Surgeons is promoting private-sector implementation of the Department of Veterans Affairs National Surgical Quality Improvement Program, a system for tracking risk-adjusted morbidity and mortality for noncardiac surgery.5,51
There is currently little empirical evidence supporting the superiority of one payer strategy over the others. Thus, payers should focus on the programs most likely to improve patients' outcomes and reduce costs while preventing undesirable side effects. In most cases, the optimal model will depend on the clinical context. Thus, on the one hand, a centers-of-excellence model is well suited to procedures in which there is a dramatic variation in outcomes among providers, with strong evidence tying outcomes to the structure of care (e.g., evidence that hospitals with higher procedure volumes have better outcomes) and few practical barriers to concentrating care within a small number of centers. Therefore, uncommon and high-risk procedures, such as pancreatic resection and esophagectomy, would be good targets for centers-of-excellence programs.
Pay for performance, on the other hand, is less useful than centers of excellence for effecting improvements in the quality of particular procedures. One limitation is that, for many operations, procedure volumes, rates of adverse events, or both are too low for reliable comparisons to be made of outcomes among individual hospitals. Even when statistical power is not an issue, the availability of high-quality clinical data to measure outcomes and for use in risk adjustment usually is an issue. Ideal targets are underused processes of care for which there is a high level of evidence linking them to important surgical outcomes (e.g., appropriate prophylaxis for patients at high risk for venous thromboembolism).
Ultimately, we believe, pay-for-participation programs offer the greatest promise for improving surgical quality. Coupled with prospective clinical registries, they offer the best potential for identifying important processes of care involved in specific procedures and for translating the collective clinical insights of surgeons into collaboratively achieved improvements in quality. These efforts face substantial organizational challenges, many because of their high costs. However, surgical complications are also very expensive, costing more than an average of $10,000 per case, according to one recent estimate.52 Thus, there is reason to hope that pay-for-participation programs will reduce payers' costs as effectively as they will improve patients' outcomes.
Dr. N.J.O. Birkmeyer and Dr. J.D. Birkmeyer report serving as codirectors of the Michigan Bariatric Surgery Collaborative, which is funded by Blue Cross and Blue Shield of Michigan and the Blue Care Network; and Dr. J.D. Birkmeyer reports serving as a consultant for the Leapfrog Group and chairing its expert panel on evidence-based hospital referral. No other potential conflict of interest relevant to this article was reported.
Source Information
From the Michigan Surgical Collaborative for Outcomes Research and Evaluation, Department of Surgery, University of Michigan, Ann Arbor.
References
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Romano PS, Zhou H. Do well-publicized risk-adjusted outcomes reports affect hospital volume? Med Care 2004;42:367-377.
Schneider EC, Epstein AM. Use of public performance reports: a survey of patients undergoing cardiac surgery. JAMA 1998;279:1638-1642.
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Dunn P. Hospital performance measures: additional priority areas available for review and comment. Press release of National Quality Forum, Washington, D.C., July 18, 2005.
Garneski S. American College of Surgeons and Blue Cross Blue Shield of Michigan partner to study outcomes for general and vascular surgery patients. Chicago: American College of Surgeons, August 2005.
Birkmeyer NJO, Share D, Campbell DA, Prager RL, Moscucci M, Birkmeyer JD. Partnering with payers to improve surgical quality: the Michigan Plan. Surgery 2005;138:1815-1820.
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Moscucci M, Montoye C, Kline-Rogers E, Smith D. Improving outcomes of percutaneous coronary interventions: the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) collaborative quality improvement initiative in percutaneous coronary interventions. In: American Heart Association Scientific Session 2003, Orlando, Fla., November 9–12, 2003.
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Dimick JB, Chen SL, Taheri PA, Henderson WG, Khuri SF, Campbell DA Jr. Hospital costs associated with surgical complications: a report from the private-sector National Surgical Quality Improvement Program. J Am Coll Surg 2004;199:531-537.(Nancy J.O. Birkmeyer, Ph.)
With regard to surgery, however, payers may need to consider different strategies to bring about improvements in quality. The quality of health care may be assessed on the basis of structure (the attributes of the setting of care), process (the details of the care provided), or outcomes (the results of care).10 In medicine, there is a relatively long list of evidence-based process measures that can readily be acted on and may be used to evaluate the quality of care. Similar process measures are generally lacking for surgery. The use of outcomes to evaluate the quality of surgical care implies the need for detailed clinical data for risk adjustment. Even if such data were widely available, outcome measures are probably less responsive to financial incentives than process measures. For example, a surgeon can immediately increase compliance with guidelines for thromboembolism prophylaxis but may not know how to reduce the risk-adjusted mortality for a given procedure.
For these reasons, payers are exploring strategies beyond pay-for-performance programs (Table 1). Some payers are reexamining centers-of-excellence strategies aimed at directing patients to hospitals that are likely to provide the best results with respect to a particular condition or procedure. Other payers are experimenting with a new, more collaborative model — called "pay for participation" — in the hope of effecting improvements in quality by underwriting the costs of clinical-outcome registries and improvement activities on the part of providers.
Table 1. Strategies to Improve Surgical Care.
In this article, we review ongoing efforts by payers to improve the quality of surgical care through these three approaches. We examine the primary strengths and weaknesses of these approaches and close with suggestions of how payers can most effectively achieve improvements in the quality of surgical care. Many would use the term "payer" more narrowly, but here we use it to mean the broad group of employers, purchasers, insurers, and health care plans that directly or indirectly pay for health care services.
Centers of Excellence
Although the term "centers of excellence" is used in many different contexts, we use it to describe programs aimed primarily at identifying hospitals that are likely to have the best results with respect to selected procedures and at directing patients to these facilities. There are many mechanisms for achieving an increase in the number of patients directed to certain facilities. Payers can use selective contracting — restricting payment for selected procedures to a small number of high-quality hospitals or surgeons. Alternatively, payers can try to persuade patients — by means of tiered health care plans and benefits packages that offer patients financial incentives (e.g., lower copayments or monthly premiums) — to choose selected high-quality providers. Patients can also be encouraged to choose their own providers (self-referral) on the basis of public reporting of information about providers in their geographic area with regard to the volume of procedures, process of care, or direct outcome measures.
Among current examples of centers-of-excellence programs, the Leapfrog Group, a large coalition of public and private employers and purchasers, is promoting "evidence-based hospital referral" for five surgical procedures, using as criteria a minimum procedure volume, selected process measures, and (for cardiac procedures) risk-adjusted mortality rates.11,12 In addition, many payers are implementing their own centers-of-excellence programs for cardiac surgery and other selected procedures. Given the skyrocketing rates of procedures and concern about the uneven quality of procedures, bariatric surgery has recently become a popular target for quality-based selective contracting.13
The centers-of-excellence model has several attractive features. Since these programs rely primarily on volume and other structural measures of quality, they can be implemented quickly and inexpensively. Recent reports suggest that a hospital's history of volume of procedures and mortality rates is a strong predictor of its performance in the future.14,15 Such data imply that many lives could be saved if selected procedures could be concentrated within hospitals that meet certain criteria.12,16
Although current indicators of quality can reliably identify groups of providers that have, on average, better results, these indicators do not reliably discriminate with respect to performance among individual hospitals or surgeons. The limitations of the use of procedure volume as an indicator of quality have been well characterized.17,18 Because of limited sample size, direct outcome measures (e.g., morbidity and mortality) are similarly flawed indicators of a hospital's true performance with respect to most procedures.19 Direct outcome measures are also limited by a lack of readily available clinical data to ensure adequate risk adjustment. Centers-of-excellence programs based on measures that do not reliably reflect provider-specific performance will continue to be viewed as unfair by both hospitals and surgeons and will be strongly opposed.
The centers-of-excellence model is also limited by a lack of reliable mechanisms for redistributing surgical patients. Given the fragmentary state of health care financing in the United States, even well-organized blocs of payers lack sufficient market share and negotiating power with hospitals to dictate surgical-referral patterns.20,21 Public payers, particularly the Centers for Medicare and Medicaid Services (CMS), may have the leverage, but they do not have the political will to take on hospitals and surgeons in order to implement selective-contracting initiatives. Efforts that rely on patients to "shop for quality" may face less resistance, but they are not likely to be very effective. Although stronger financial incentives than are now available may ultimately direct more patients toward centers of excellence, there is little evidence to date that public reporting of data on surgical performance has a substantial effect on patients' decisions or hospitals' caseloads.22,23
Pay for Performance
Rather than direct more patients in need of surgical care to the best hospitals or surgeons, pay-for-performance programs are aimed at encouraging improvements in quality in all settings. In contrast to centers-of-excellence programs, in which rewards take the form of increases in the volume of patients, pay-for-performance programs reward superior surgical quality with direct financial bonuses.
A growing number of payers are implementing pay-for-performance programs in surgery. In a demonstration project begun in 2004, the CMS will pay a reimbursement premium of up to 2 percent to hospitals scoring in the top 20 percent (calculated on the basis of a composite of process and outcome measures) for coronary-artery bypass surgery and surgery for hip or knee replacement.24 By year 3 of the project, hospitals with the worst performance record will be penalized financially.24 The Surgical Care Improvement Project, which was jointly initiated by the CMS and the Centers for Disease Control and Prevention, is promoting several evidence-based processes for the purpose of pay for performance. One of these processes — the timely and appropriate use of perioperative antibiotic drugs — has already been adopted in pay-for-performance plans by Blue Cross and Blue Shield (BCBS) and other large private payers.25 Similar initiatives aimed at preventing postoperative cardiac events, venous thromboembolism, and respiratory complications have also been launched.26,27
Although empirical data establishing the effectiveness of this approach, as compared with others, are lacking, pay-for-performance programs have the potential to achieve rapid and substantial improvements in many aspects of clinical care. At the University of Michigan Hospital, for example, the proportion of patients undergoing colorectal surgery who receive an appropriate antibiotic within 60 minutes before the incision increased virtually overnight, from about 70 percent to more than 95 percent, after the implementation of a pay-for-performance program by one of the hospital's major private payers. Similar improvements might be expected for other aspects of surgical care.
As is the case in the centers-of-excellence model, pay for performance is hindered by a lack of good measures with which to assess the performance of hospitals or surgeons. As already mentioned, provider-specific outcome measures are limited by constraints on sample size and a paucity of sources of the clinical data needed to ensure adequate risk adjustment.19 Despite their predominance in pay-for-performance plans involving primary care, process-of-care measures are less useful indicators of the quality of surgical care. Most such measures are related to aspects of general perioperative care and secondary outcomes (e.g., use of antibiotics to reduce rates of infections at the surgical site). Although these measures may reflect low-hanging fruit, it is not clear that improvements in these aspects of perioperative care would reduce the observed variations in even more important outcomes (e.g., mortality) among hospitals and surgeons. For most procedures, high-leverage processes of care, particularly those specific to a particular surgical procedure, have yet to be identified.
Pay for Participation
The newest strategy for payer-led improvements in surgical quality is pay for participation. According to this model, payers provide the infrastructure and resources for hospitals and surgeons to collaborate with one another to evaluate and improve the quality of surgical care. Hospitals and surgeons are compensated simply for their participation in these collaborative activities, not for individual performance or for the extent of their improvement over time. Instead, effectiveness is judged in terms of collective improvements in morbidity, mortality, and costs.
Pay-for-participation programs have two essential components. The first component is high-quality clinical-outcomes data, which include procedure-specific information on patient characteristics required for risk adjustment, processes of care, and relevant outcomes. The content of the clinical-data registry may be specifically developed for this purpose or may have been developed previously (e.g., the Society of Thoracic Surgeons database is being used in one of the Michigan pay-for-participation programs). Either way, the data are collected prospectively by trained data abstracters, with the use of standardized definitions, and are audited externally for accuracy and completeness.
To achieve improvements in surgical quality in the pay-for-participation model, at regular intervals surgeons and hospitals receive timely feedback on their performance relative to that of their peers. At meetings at regular intervals, surgeons and program coordinators review the performance data on the surgeons and hospitals and the analyses linking specific processes to outcomes. Participants develop plans for specific interventions to achieve improvements, which, under the direction of program coordinators, are implemented at all hospitals. These interventions are later evaluated empirically, discussed at follow-up meetings, and refined.
Although such efforts are now in the early stages of development in other states, in Michigan programs funded and developed by Blue Cross and Blue Shield of Michigan and Blue Care Network (BCBSM) may become the prototypes for pay-for-participation programs in surgery.28,29 Patterned on an established program in interventional cardiology,30,31,32 there are now three separate initiatives targeting cardiac surgery, bariatric surgery, and other general and vascular surgery that include more than 20 of the largest hospitals in the state. Although the programs in Michigan vary in their details,29 in each case hospitals are compensated for data collection and participation in improvement activities in the form of supplements to reimbursements according to the diagnosis-related group for surgical care.
Surgeons' acceptance of this approach is one of the major advantages of pay-for-participation programs. In most current programs, performance data are not publicly reported (and are not shared even with the underwriting payer), and thus, there are no winners or losers. This approach also has the potential to be very effective in improving surgical quality. Previous regional collaborations for improving surgical quality, although most of them were not funded by payers, markedly improved surgical outcomes in cardiac surgery and surgery for rectal cancer.6,7,33,34 A pay-for-participation program in interventional cardiology has also been effective,31 showing significant improvement in providers' adherence to evidence-based best practices. Patients' outcomes have also improved, as reflected by statewide reductions in mortality, unplanned coronary-artery bypass surgery, myocardial infarctions, nephropathy induced by the administration of contrast medium, and stroke after percutaneous coronary interventions.31
Pay-for-participation plans are difficult to organize. Hospitals and surgeons are more accustomed to competing against one another than to collaborating. They also have no direct financial incentives to take part in such plans. Payers cover the costs of data collection and quality-improvement activities, but no one profits financially from pay-for-participation programs. Finally, hospitals and surgeons tend to distrust the motives of payers and worry that pay for participation is just a pretext for collecting data that will ultimately be used for the purposes of selective contracting, public reporting, or both.
Motivating payers to participate may be equally challenging. Although in Michigan one payer (BCBSM) has a dominant market share, in most other regions there are numerous payers, each covering a relatively small proportion of the market. Providers, like payers, have few precedents for collaborating with one another to achieve quality improvement. Pay-for-participation plans are also very expensive. In Michigan alone, the three pay-for-participation programs in surgery combined cost approximately $5 million a year. Most payers will need to be convinced of the business case for quality — that their investment will be returned in the form of reductions in the morbidity, mortality, and costs associated with surgical complications.
Finally, the lack of public reporting in current pay-for-participation initiatives may limit support for these programs. In the context of quality improvement, the value of public reporting is hotly debated.35,36,37,38,39 Proponents argue that public reporting provides a necessary accountability and stimulates rapid improvement.40,41,42 They also cite the moral argument that patients have a basic right to know about differences in outcomes among providers and that such information is central to informed consent.43,44 Opponents counter that public reporting induces gaming and other unwanted behavior among providers (e.g., surgeons' avoiding high-risk patients) and deters physicians from collaborating in the measurement of the quality of care and in improvement activities.45,46,47 On the basis of our observations in Michigan, public reporting was a "deal breaker" for many hospitals and surgeons who were invited to collaborate in the BCBSM programs. In the future, evidence that pay-for-participation programs reduce variation in providers' performance may help to diminish the pressure for public reporting. Alternatively, surgeons and hospitals participating in these programs may grow less defensive about the reporting of data on their performance and relax their opposition to public disclosure.43,44,48,49
Conclusions
Although the different strategies by which payers can leverage improvements in quality each have distinct strengths and weaknesses, the boundaries of the three models are not always as distinct as implied in this review. For example, centers-of-excellence programs may be mainly about directing more patients to the best facilities, but they may also motivate improvement more broadly to the extent that hospitals and surgeons try harder to be the "best." Similarly, the primary goal of pay-for-performance programs may be broad-based quality improvements, but programs that include public reporting may also help to steer surgical patients to hospitals that have the best performance.
Although this article focuses on programs initiated by payers, other groups have their own strategies for effecting improvements in the quality of surgical care. For example, in several states the departments of health have implemented successful public-reporting initiatives in cardiac surgery.6,50 The American College of Surgeons is promoting private-sector implementation of the Department of Veterans Affairs National Surgical Quality Improvement Program, a system for tracking risk-adjusted morbidity and mortality for noncardiac surgery.5,51
There is currently little empirical evidence supporting the superiority of one payer strategy over the others. Thus, payers should focus on the programs most likely to improve patients' outcomes and reduce costs while preventing undesirable side effects. In most cases, the optimal model will depend on the clinical context. Thus, on the one hand, a centers-of-excellence model is well suited to procedures in which there is a dramatic variation in outcomes among providers, with strong evidence tying outcomes to the structure of care (e.g., evidence that hospitals with higher procedure volumes have better outcomes) and few practical barriers to concentrating care within a small number of centers. Therefore, uncommon and high-risk procedures, such as pancreatic resection and esophagectomy, would be good targets for centers-of-excellence programs.
Pay for performance, on the other hand, is less useful than centers of excellence for effecting improvements in the quality of particular procedures. One limitation is that, for many operations, procedure volumes, rates of adverse events, or both are too low for reliable comparisons to be made of outcomes among individual hospitals. Even when statistical power is not an issue, the availability of high-quality clinical data to measure outcomes and for use in risk adjustment usually is an issue. Ideal targets are underused processes of care for which there is a high level of evidence linking them to important surgical outcomes (e.g., appropriate prophylaxis for patients at high risk for venous thromboembolism).
Ultimately, we believe, pay-for-participation programs offer the greatest promise for improving surgical quality. Coupled with prospective clinical registries, they offer the best potential for identifying important processes of care involved in specific procedures and for translating the collective clinical insights of surgeons into collaboratively achieved improvements in quality. These efforts face substantial organizational challenges, many because of their high costs. However, surgical complications are also very expensive, costing more than an average of $10,000 per case, according to one recent estimate.52 Thus, there is reason to hope that pay-for-participation programs will reduce payers' costs as effectively as they will improve patients' outcomes.
Dr. N.J.O. Birkmeyer and Dr. J.D. Birkmeyer report serving as codirectors of the Michigan Bariatric Surgery Collaborative, which is funded by Blue Cross and Blue Shield of Michigan and the Blue Care Network; and Dr. J.D. Birkmeyer reports serving as a consultant for the Leapfrog Group and chairing its expert panel on evidence-based hospital referral. No other potential conflict of interest relevant to this article was reported.
Source Information
From the Michigan Surgical Collaborative for Outcomes Research and Evaluation, Department of Surgery, University of Michigan, Ann Arbor.
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