Speaker says pay-for-performance is on its way whether or not spine surgeons like it

The information available to date about the shift to the pay-for-performance model in health care suggests it can be cost effective, but this evidence is not yet convincing, according to a presenter.

The new payment model for reimbursement is a tricky proposition for surgeons across every specialty, Stephen Bartol, MD, MBA, FRCSC, of Detroit, said during a symposium on implementing accountable care in spine surgery.

Stephen Bartol

For a general practitioner, overall payment targets are much easier to define with pay-for-performance (PFP); targets are easy for such things as treating diabetes or patients with high blood pressure, but questions remain about how payment targets would be defined for surgeons.

“The problem is, the measures that are in place do not actually reflect the value of what we do. Surgeons want to know things like, did I use the right judgment about whether or not I should operate and when to operate? What procedure to use? How is my technical skill measuring up in the operating room? Those are the things that reflect value, but those things are difficult to quantify and measure. As a result, the payers are using surrogate targets,” Bartol said.

PFP targets off base

Payers do not want to know how good a surgeon is in the operating room in some of the PFP models, but they do want to know if the surgeon kept the patient warm during surgery, Bartol noted.

“I would submit that the measures in place today are not fair. Pay-for-performance is focusing on easy to obtain metrics and not on the things that matter to us or to patients, and that is the problem. In fact, the National Quality Forum Panel, commissioned by Obama this year, came out with the frank statement that pay-for- performance is not fair. I would argue PFP in many cases really equals punishment-for-performance,” he said.

To inform surgeons more about the potential payment change from fee for service, Bartol discussed in his presentation the Continuous Quality Improvement (CQI) program developed by the Michigan Spine Surgery Improvement Collaborate (MSSIC). The CQI is based on a system of feedback using systematically collected data and information provided during regular meetings that involve CQI program participants, said Bartol, who is co-director of the MSSIC.

A new PFP model

The MSSIC began collecting data for the program’s database in collaboration with Blue Cross Blue Shield of Michigan (BCBS of Michigan) in the first quarter of 2014. The MSSIC-collected data included information related to surgical decision making, procedures, complications and outcome measurements such as the Oswestry Disability Index, Neck Disability Index, EuroQol-5D, VAS, and Japanese Orthopaedic Association scales, according to Bartol.

The program’s operational costs are paid for by BCBS of Michigan, and the data are owned by MSSIC surgeons.

He said payments are currently based mostly on participation, but this approach will evolve as the program expands.

“Partial performance is rewarded. You get some credit for trying,” Bartol said. “Payments are added to your fee-for-service payments, so it is a reward, not a punishment. Targets evolve over time to reflect value as determined by the surgeons, and over time the weight shifts from participation to performance,” he said.

If PFP is expected to work, it must provide the correct amount of money, must include the correct information and have the correct accountability standards, according to Bartol, who noted the landscape is constantly changing and PFP is real.

Prepare for PFP

“To prepare for it, organize someone in your practice to become an expert and enlist the hospital for support. Most of the money goes to the hospital, so work with them, not against them. Help them. Let them know you can help them because you are the expert, but expect help from them in return,” Bartol said.

However, surgeons must begin tracking what is meaningful in terms of outcomes from a surgery. Bartol suggested they start doing that with length of stay and 30-day re-admittance rates.

He also recommended keeping the lines of communication open to better prepare for the PFP model.

“Above all, start communicating with the private payers. Let them know you are the expert. Let them know what you are doing to track performance and improve quality, and offer to participate and work together with them. At the end of the day, you need to win with your data and take charge,” Bartol said.

He noted in his program the activities for which physicians are paid include participation, quarterly meetings, conference calls data gathering and having all needed documentation in place. – by Robert Linnehan

Reference:

Bartol S. Payment models: Shift from fee for service to pay for performance. Presented at: North American Spine Society Annual Meeting; Nov. 12-15, 2014; San Francisco.

For more information:

Stephen Bartol, MD, MBA, FRCSC, can be reached at Henry Ford Hospital, 2799 W. Grand Blvd., Detroit, MI; email: sbartol1@hfhs.org.

Disclosure: Bartol reports he has private investments in and is a board member for Sentio, he is a consultant to DePuy Synthes, is a member of the scientific advisory board for Musculoskeletal Transplant Foundation and receives a researcher support-investigator salary from BCBS of Michigan.