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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
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
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