Intersection of Surgical Outcomes and Medical Education A CMO’s Perspective

1. Intersection of Surgical Outcomes and Medical EducationA 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?

2. 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”

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).

4. 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

5. Direction Of Health Reform Is Uncertain.... Level of financial risk borne by payor Level of financial risk borne by provider ...but all models involve performance measurement and accountability Global Capitation P4P Medical Home Bundled Payments Fee for Service Adapted from Dr. James Mongan presentation 5/26/2009

6. 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

7. Procedure Cost Assessment Average Direct Cost per Inpatient Discharge Total Knee Replacement - OR Related Costs - FY11 7

8. Surgeon-specific Metrics The Next Generation?

9. Porter ME. NEJM 2012

10. Procedure Decision Support Carotid Stenosis QPID Appropriate Procedure Order Carotid Stenosis Therapy : Evidence Based Guidelines Step 1: Indications with exceptions >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) Step 3: Shared decision making Patient has received a decision aid Print Personalized Consent Schedule Surgery Risk Calculator: 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% Step 2: Perioperative risk assessment Step 4: Outputs If guideline criteria not met, but patient still requires surgery, add justification here Print Personalized Consent Schedule Surgery

12. 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

13. The future ain’t what it used to be. Y. Berra Y. Berra