- Joined
- Nov 13, 2006
- Messages
- 47
- Reaction score
- 0
This is the trend in surgery. Get Out while you can!
General Surgery News
ISSUE: 12/2006 | VOLUME: 33:12
Payformance
David V. Cossman MD
In 1977, the year I started practice, Medicare paid me $3,500 to perform a carotid endarterectomy. Patients would come into the hospital the day before for an arteriogram. On hospital day 3, wed check the creatinine. On the fourth day, the patient would have surgery performed by me with a board-certified vascular surgeon as my assistant. The patient would then be moved to the intensive care unit. On the fifth day, the patient would go to the ward. On day 6, the stitch would come out, and on the seventh day, the patient would go home and rest. Heaven and earth were in alignment. Life was good.
My stroke rate was 3%. Acceptable for the times.
I loved surgery so much, I thought I was overpaid. That feeling has not been a problem for quite some time. My senior partner had to slap me around to make me come to my senses.
Last year, an 80-year-old patient needing a carotid endarterectomy would arise at 4 a.m. to come to the hospital in the dark to have surgery at 7 a.m. Arteriograms with the attendant risks have been eliminated by an accurate and safe $100 Doppler ultrasound. I do the operation with a resident. The patient goes home about 24 hours after he or she was admitted.
My stroke rate is less than 1%. Acceptable for the times.
Medicare pays me $800less in real terms than they paid my assistant in 1977. Im the senior partner now, so theres no one to slap me around.
So whats this Ive been hearing about pay for performance? No new healthcare initiative gets launched without an acronym or catchy little slogan, so lets try the portmanteau payformance. I have little doubt that our august leaders will swallow this one hook, line and sinker, just as they have the 80-hour workweek, the JCAHO (Joint Commission on Accreditation of Healthcare Organizations), legalized tagging of patients in the operating room, SBAR (100 bucks to anyone who knows what that stands for), obsessive handwashing, and other ritualistic acts of obeisance to the compliance monster that has attached itself to the soft underbelly of our once-noble profession. But honestly, given the steep and divergent trajectories of pay and performance in surgery during the past two decades, what, short of multi-infarct dementia, would allow any of us to believe that all of a sudden, doing a good job will bring financial reward?
Clearly, the exact opposite of payformance has happened in the past 20 years. We have been victimized by our own success. Operations that were once celebrated as monumental achievements of surgical science have been discounted and trivialized because they are done so often and so well by so many. A liver transplant gets a big yawn today from third-party payers.
Let the record show, please, that our dazzling successes of the past quarter-century occurred before the current obsession with report cards, Healthgrades.com and publication of results for commonly performed procedures. While the New England Journal of Medicine boasted recently that publication of outcomes for coronary artery bypass grafts in New York was responsible for reducing mortality to 1% from 1.5%, it neglected to acknowledge the breathtaking improvements in heart surgery the 15 years prior.
Remember the last time our trusted policy-makers promised the medical profession a raise by recategorizing everything we did into RBRVUs (resource-based relative value scales)? The program was designed to reward cognition at the expense of procedures and operations, which many view as primitive acts that require as much intellectural input as the cremasteric reflex. The program should have been dubbed a penny for your thoughts because thats exactly what our internist colleagues wound up getting. How smart could they possibly be to have fallen for this ruse?
The problem with paying for cognition is exactly the same as it will be with payformance. No one knows what to measure or how to measure it, and inevitably, people measure what they can or what they know, not whats important. Ever notice how the laminated movie stars sitting courtside in the expensive seats at the Los Angeles Lakers games jump up and down at exactly the wrong time? God only knows what theyre reacting to, but apparently its not the same thing as the knowledgeable fans in the nosebleed section.
Measuring cognition seemed easy enough. All you had to do was attach a thermography recorder to the forehead of the cogitating internist and assign a dollar value to temperature tracings of the smoke coming out of his ears. Regrettably, these devices intefered with cell service in the hospital, so monetizing thoughtful gestures like stroking your beard (women objected) and furrowing your brow (California internists objected because 27% of them have had Botox injections) was tried. As one would expect, the metrics used to quantify thought were antithetical to it. Long H&Ps and differential diagnoses were rewarded instead of clarity. Staying up all night thinking about the next days surgery didnt qualify as cognition because it didnt satisfy the mantra of the modern-day bean countersIf its not documented, it didnt happen. In the end, the program that purported to celebrate the ascendency of thought was nothing but a chirade to cut costs. Reimbursement for everything other than thought was slashed, including the cash cows of the office-based practitioners like EKGs and labs. At least it came at a time when EOBs were fairly flush.
Now comes across the already financially scorched medical landscape a man holding bags of money, telling us cognition is so yesterday and hes going to pay us for performance.
Performance. Is that what the man said? Performance. Where was he with his bags of money during the last 20 years when my stroke rate fell by a factor of 10 and patients were out of the hospital before theyve soiled the sheets? Where did the savings go?
Performance. He didnt say results, did he? Did he say quality? No, I think I hear performance. Why did we think when we first heard performance that we heard good results? No, I think he means performance, and performance is exactly the right word. It has the ring of jumping through hoops, does it not? God only knows what they have in mind by performance, but clearly its unrelated to the spectacular improvement in surgical care weve all been party to in the past quarter-century. Thats taken for granted. No one seems inclined to acknowledge that all this happened without the oversight and compliance menace that is sucking the life out of our profession. No, I think performance is going to have a very special meaning to those who have put themselves in charge of measuring it. Just as when we found out that the meaning of cognition was ink on a page, the meaning of payformance will be sure to dazzle.
Payformance that actually rewarded healthcare stars would very likely make the whole healthcare delivery system quite sick for three reasons.
The first is that access to care is really more important than quality when the needs of society as a whole are taken into account. Now that my flak jacket is on, let me explain. If healthcare is to be viewed as an essential right or need, like food and shelter, then access and distribution are more important than quality. We have McDonalds and Wendys restaurant chains, not Le Cirques and LOrangeries. Dont forget, we live in a society where a large chunk of the New Orleans population couldnt get out of the way of Katrina. Splitting hairs over whether the hospital in Shaker Heights does a better hip than the one in Coral Gables doesnt really do much for the overall healthcare needs of society. Hospitals are in love with payformance because they see it as a great marketing tool in the local marketplace, but would a few million dollars be of greater service to society used to buy a 25th MRI machine for the Cleveland Clinic or immunize 5,000 kids against disease?
The second reason is related to the first. Healthcare by necessity is local. The homies dont like taking out the stitches when Patient X comes home from Houston, where he had his bypass. A true pay-for-performance system would inevitably promote regionalism in healthcare distribution and would slowly dismantle the already disintegrating healthcare grid that services the American people and its visitors. Could the same man from New Orleans who found himself on top of his roof when the levees broke be reasonably expected to find his way to the next county when he needs a lap Nissen because their results are better than those at the local hospital?
The third reason why a bona fide payformance system would be a disaster is that really sick people would find it difficult to get care. A 79-year-old man with diabetes, triple-vessel coronary disease and borderline renal failure who requires coronary revascularization is viewed as a challenge in todays medical world, requiring the full-court press and all the best that modern medicine has to offer. In a true payformance world, that patient is going to be viewed as a threat to ones rankings. Risk-averse healthcare delivery masquerading as medical prudence will sweep the nation. If you die without anyone trying, no provider will get dinged for your loss. The profession is going to be looking at a lot of called strike 3s without taking the bat off its shoulder.
The policy-makers know all this, so payformance will have nothing to do with actual results, just like RBRVUS had nothing to do with productive thought. Payformance will be just another iteration of a centrally mediated and heavily regulated program that seeks to control provider costs and conduct in the name of quality. Its no different from politicians invoking national security to get their agendas passed. Evocation of high-minded principles nullifies opposition and makes critics appear to be against quality, or patriotism.
Ironically, the payformance ruse will be inflationary to the overall cost of healthcare while it robs the last few shekels from the poor providers for imaginary transgressions. It wont be inflationary because theyre going to be passing out money to good providers. Large healthcare providers like big hospitals and health plans will hire countless more functionaries with big salaries and clipboards to satisfy the regulatory beast that intends to evaluate performance. Most of us with small operations will just plead nolo contendere and not waste our time doing homework for extra credit to get the gold star.
I dont know what form obedience training will take this time, but Im pretty sure it will have something to do with documentation, patient satisfaction and compliance with core measures and other transitory obsessions of the day because those seem to be the only things regulators know how to count. A good operation will not judged by outcome or execution, but by the operative report. And not the part that comes after the patient was prepped and draped in the usual fashion, but the part that comes before.
To be in the top 1% to 2% (oh, I forgot to tell you, only the top 1% to 2% will get consideration as the rest of you are inadequate) and qualify for a $20 bonus, the part before the patient was prepped and draped in the usual fashion should read like this (failure to do so will result in a fine and public pillory).
After the patient was independently identified by the nurse, the surgeon, the anesthesiologist and the patients daughter by cross-referencing the bar code on her hospital ID with her drivers license, hospital database and 2000 Census figures, and confirming the nature and side of the procedure and tatooing the word yes in cerulean blue ionic block letters over the patients left breast (or si, or oui, or ja, or dah, or hai, or shi, to preserve the spirit of multiculturalism and diversity) and after the patients pain level was documented to be a smiley face with only a slight downturn to the lower lip, and after full informed consent was obtained from the unsedated patient that disclosed all traditional and nontraditional alternative treatments including, but not limited to, herbalism and aroma therapy, and after the patients code status was confirmed to be full code by the patient and her advocate daughter, who holds durable medical power of attorney in the event of incapacitation, and after all members present in the operating room introduced themselves to each other and to the patient and represented that their purified protein derivatives were negative and up-to-date and that they would individually and serverally abide by the latest revision of the hospitals code of conduct and treat all present with mutual respect independent of race, religion or national origin (political affiliation exempted by popular decree) and after the antibiotics were given at 14:28, the patient was finally brought into the operating room at 15:55 with the approval of the fire marshal, chaplain and patients rights advocate. I have personally affixed a patient satisfaction questionnaire to the chart and certify under penalty of perjury it will be filled out prior to discharge. I further certify that I will protect the privacy of this patients healthcare information. We can dispense with the part that comes after the patient was prepped and draped because it will be of no interest to anyone.
The great tragedy of the inevitable degradation of the concept of payformance is that despite the real threats to access and distribution discussed above, true competition based on outcomes and not compliance is the only realistic way to reign in costs. In every other segment of a competitive economy, quality lowers costs by directing customer flow to the best providers, who leverage their success into wider distribution and further product enhancements. The efficient use of capital by the best providers ensures market dominance in the future. In healthcare, the flow of business is determined not by quality and results, but by which club you belong to (managed care), and profitablity depends on withholding services instead of enhancing them. Profits are not used for product enhancement and to reward those responsible, but to enrich those few who can figure out how to meet regulatory requirements with as little investment as possible (hospital administrators and insurance executives). Profit is realized by rationing care instead of improving it. The true absence of competition based on real performance standards leads to a disconnection between cost and quality in healthcare that does not exist in other markets. Were it not for the fact that society has decided to keep throwing more and more money at healthcare, as they have with the public school system, both would have and should have been out of business long ago. The healthcare economy, unlike the one that makes planes, trains and automobiles, and the one that provides other essentials like food, clothing and shelter, is a zero sum enterprise because profits realized by being good at something are not distributed to those responsible. Instead, savings realized by rationing care and making 80-year-olds get up in the middle of the night to get to the hospital for 7 a.m. surgery are distributed as profit to those who have contributed absolutely nothing. Now, theyre going to be rewarded futher in the name of payformance and were going to be chastised as slackers.
The payformance system coming down the pike is from the same people who brought you HIPAA, JCAHO, corporate compliance and the RBRVU system. It will do nothing to control cost or reward quality. It will be inflationary and paralyze us in yet another compliance nightmare from which we cannot awaken. I cant wait for some prune-faced regulator to show up in my office and put a big C- on my front door. That should be good for business.
Dr. Cossman is the medical director of the vascular laboratory, the director of vascular trauma and the director of resident education in vascular surgery at Cedars-Sinai Medical Center in Los Angeles.
General Surgery News
ISSUE: 12/2006 | VOLUME: 33:12
Payformance
David V. Cossman MD
In 1977, the year I started practice, Medicare paid me $3,500 to perform a carotid endarterectomy. Patients would come into the hospital the day before for an arteriogram. On hospital day 3, wed check the creatinine. On the fourth day, the patient would have surgery performed by me with a board-certified vascular surgeon as my assistant. The patient would then be moved to the intensive care unit. On the fifth day, the patient would go to the ward. On day 6, the stitch would come out, and on the seventh day, the patient would go home and rest. Heaven and earth were in alignment. Life was good.
My stroke rate was 3%. Acceptable for the times.
I loved surgery so much, I thought I was overpaid. That feeling has not been a problem for quite some time. My senior partner had to slap me around to make me come to my senses.
Last year, an 80-year-old patient needing a carotid endarterectomy would arise at 4 a.m. to come to the hospital in the dark to have surgery at 7 a.m. Arteriograms with the attendant risks have been eliminated by an accurate and safe $100 Doppler ultrasound. I do the operation with a resident. The patient goes home about 24 hours after he or she was admitted.
My stroke rate is less than 1%. Acceptable for the times.
Medicare pays me $800less in real terms than they paid my assistant in 1977. Im the senior partner now, so theres no one to slap me around.
So whats this Ive been hearing about pay for performance? No new healthcare initiative gets launched without an acronym or catchy little slogan, so lets try the portmanteau payformance. I have little doubt that our august leaders will swallow this one hook, line and sinker, just as they have the 80-hour workweek, the JCAHO (Joint Commission on Accreditation of Healthcare Organizations), legalized tagging of patients in the operating room, SBAR (100 bucks to anyone who knows what that stands for), obsessive handwashing, and other ritualistic acts of obeisance to the compliance monster that has attached itself to the soft underbelly of our once-noble profession. But honestly, given the steep and divergent trajectories of pay and performance in surgery during the past two decades, what, short of multi-infarct dementia, would allow any of us to believe that all of a sudden, doing a good job will bring financial reward?
Clearly, the exact opposite of payformance has happened in the past 20 years. We have been victimized by our own success. Operations that were once celebrated as monumental achievements of surgical science have been discounted and trivialized because they are done so often and so well by so many. A liver transplant gets a big yawn today from third-party payers.
Let the record show, please, that our dazzling successes of the past quarter-century occurred before the current obsession with report cards, Healthgrades.com and publication of results for commonly performed procedures. While the New England Journal of Medicine boasted recently that publication of outcomes for coronary artery bypass grafts in New York was responsible for reducing mortality to 1% from 1.5%, it neglected to acknowledge the breathtaking improvements in heart surgery the 15 years prior.
Remember the last time our trusted policy-makers promised the medical profession a raise by recategorizing everything we did into RBRVUs (resource-based relative value scales)? The program was designed to reward cognition at the expense of procedures and operations, which many view as primitive acts that require as much intellectural input as the cremasteric reflex. The program should have been dubbed a penny for your thoughts because thats exactly what our internist colleagues wound up getting. How smart could they possibly be to have fallen for this ruse?
The problem with paying for cognition is exactly the same as it will be with payformance. No one knows what to measure or how to measure it, and inevitably, people measure what they can or what they know, not whats important. Ever notice how the laminated movie stars sitting courtside in the expensive seats at the Los Angeles Lakers games jump up and down at exactly the wrong time? God only knows what theyre reacting to, but apparently its not the same thing as the knowledgeable fans in the nosebleed section.
Measuring cognition seemed easy enough. All you had to do was attach a thermography recorder to the forehead of the cogitating internist and assign a dollar value to temperature tracings of the smoke coming out of his ears. Regrettably, these devices intefered with cell service in the hospital, so monetizing thoughtful gestures like stroking your beard (women objected) and furrowing your brow (California internists objected because 27% of them have had Botox injections) was tried. As one would expect, the metrics used to quantify thought were antithetical to it. Long H&Ps and differential diagnoses were rewarded instead of clarity. Staying up all night thinking about the next days surgery didnt qualify as cognition because it didnt satisfy the mantra of the modern-day bean countersIf its not documented, it didnt happen. In the end, the program that purported to celebrate the ascendency of thought was nothing but a chirade to cut costs. Reimbursement for everything other than thought was slashed, including the cash cows of the office-based practitioners like EKGs and labs. At least it came at a time when EOBs were fairly flush.
Now comes across the already financially scorched medical landscape a man holding bags of money, telling us cognition is so yesterday and hes going to pay us for performance.
Performance. Is that what the man said? Performance. Where was he with his bags of money during the last 20 years when my stroke rate fell by a factor of 10 and patients were out of the hospital before theyve soiled the sheets? Where did the savings go?
Performance. He didnt say results, did he? Did he say quality? No, I think I hear performance. Why did we think when we first heard performance that we heard good results? No, I think he means performance, and performance is exactly the right word. It has the ring of jumping through hoops, does it not? God only knows what they have in mind by performance, but clearly its unrelated to the spectacular improvement in surgical care weve all been party to in the past quarter-century. Thats taken for granted. No one seems inclined to acknowledge that all this happened without the oversight and compliance menace that is sucking the life out of our profession. No, I think performance is going to have a very special meaning to those who have put themselves in charge of measuring it. Just as when we found out that the meaning of cognition was ink on a page, the meaning of payformance will be sure to dazzle.
Payformance that actually rewarded healthcare stars would very likely make the whole healthcare delivery system quite sick for three reasons.
The first is that access to care is really more important than quality when the needs of society as a whole are taken into account. Now that my flak jacket is on, let me explain. If healthcare is to be viewed as an essential right or need, like food and shelter, then access and distribution are more important than quality. We have McDonalds and Wendys restaurant chains, not Le Cirques and LOrangeries. Dont forget, we live in a society where a large chunk of the New Orleans population couldnt get out of the way of Katrina. Splitting hairs over whether the hospital in Shaker Heights does a better hip than the one in Coral Gables doesnt really do much for the overall healthcare needs of society. Hospitals are in love with payformance because they see it as a great marketing tool in the local marketplace, but would a few million dollars be of greater service to society used to buy a 25th MRI machine for the Cleveland Clinic or immunize 5,000 kids against disease?
The second reason is related to the first. Healthcare by necessity is local. The homies dont like taking out the stitches when Patient X comes home from Houston, where he had his bypass. A true pay-for-performance system would inevitably promote regionalism in healthcare distribution and would slowly dismantle the already disintegrating healthcare grid that services the American people and its visitors. Could the same man from New Orleans who found himself on top of his roof when the levees broke be reasonably expected to find his way to the next county when he needs a lap Nissen because their results are better than those at the local hospital?
The third reason why a bona fide payformance system would be a disaster is that really sick people would find it difficult to get care. A 79-year-old man with diabetes, triple-vessel coronary disease and borderline renal failure who requires coronary revascularization is viewed as a challenge in todays medical world, requiring the full-court press and all the best that modern medicine has to offer. In a true payformance world, that patient is going to be viewed as a threat to ones rankings. Risk-averse healthcare delivery masquerading as medical prudence will sweep the nation. If you die without anyone trying, no provider will get dinged for your loss. The profession is going to be looking at a lot of called strike 3s without taking the bat off its shoulder.
The policy-makers know all this, so payformance will have nothing to do with actual results, just like RBRVUS had nothing to do with productive thought. Payformance will be just another iteration of a centrally mediated and heavily regulated program that seeks to control provider costs and conduct in the name of quality. Its no different from politicians invoking national security to get their agendas passed. Evocation of high-minded principles nullifies opposition and makes critics appear to be against quality, or patriotism.
Ironically, the payformance ruse will be inflationary to the overall cost of healthcare while it robs the last few shekels from the poor providers for imaginary transgressions. It wont be inflationary because theyre going to be passing out money to good providers. Large healthcare providers like big hospitals and health plans will hire countless more functionaries with big salaries and clipboards to satisfy the regulatory beast that intends to evaluate performance. Most of us with small operations will just plead nolo contendere and not waste our time doing homework for extra credit to get the gold star.
I dont know what form obedience training will take this time, but Im pretty sure it will have something to do with documentation, patient satisfaction and compliance with core measures and other transitory obsessions of the day because those seem to be the only things regulators know how to count. A good operation will not judged by outcome or execution, but by the operative report. And not the part that comes after the patient was prepped and draped in the usual fashion, but the part that comes before.
To be in the top 1% to 2% (oh, I forgot to tell you, only the top 1% to 2% will get consideration as the rest of you are inadequate) and qualify for a $20 bonus, the part before the patient was prepped and draped in the usual fashion should read like this (failure to do so will result in a fine and public pillory).
After the patient was independently identified by the nurse, the surgeon, the anesthesiologist and the patients daughter by cross-referencing the bar code on her hospital ID with her drivers license, hospital database and 2000 Census figures, and confirming the nature and side of the procedure and tatooing the word yes in cerulean blue ionic block letters over the patients left breast (or si, or oui, or ja, or dah, or hai, or shi, to preserve the spirit of multiculturalism and diversity) and after the patients pain level was documented to be a smiley face with only a slight downturn to the lower lip, and after full informed consent was obtained from the unsedated patient that disclosed all traditional and nontraditional alternative treatments including, but not limited to, herbalism and aroma therapy, and after the patients code status was confirmed to be full code by the patient and her advocate daughter, who holds durable medical power of attorney in the event of incapacitation, and after all members present in the operating room introduced themselves to each other and to the patient and represented that their purified protein derivatives were negative and up-to-date and that they would individually and serverally abide by the latest revision of the hospitals code of conduct and treat all present with mutual respect independent of race, religion or national origin (political affiliation exempted by popular decree) and after the antibiotics were given at 14:28, the patient was finally brought into the operating room at 15:55 with the approval of the fire marshal, chaplain and patients rights advocate. I have personally affixed a patient satisfaction questionnaire to the chart and certify under penalty of perjury it will be filled out prior to discharge. I further certify that I will protect the privacy of this patients healthcare information. We can dispense with the part that comes after the patient was prepped and draped because it will be of no interest to anyone.
The great tragedy of the inevitable degradation of the concept of payformance is that despite the real threats to access and distribution discussed above, true competition based on outcomes and not compliance is the only realistic way to reign in costs. In every other segment of a competitive economy, quality lowers costs by directing customer flow to the best providers, who leverage their success into wider distribution and further product enhancements. The efficient use of capital by the best providers ensures market dominance in the future. In healthcare, the flow of business is determined not by quality and results, but by which club you belong to (managed care), and profitablity depends on withholding services instead of enhancing them. Profits are not used for product enhancement and to reward those responsible, but to enrich those few who can figure out how to meet regulatory requirements with as little investment as possible (hospital administrators and insurance executives). Profit is realized by rationing care instead of improving it. The true absence of competition based on real performance standards leads to a disconnection between cost and quality in healthcare that does not exist in other markets. Were it not for the fact that society has decided to keep throwing more and more money at healthcare, as they have with the public school system, both would have and should have been out of business long ago. The healthcare economy, unlike the one that makes planes, trains and automobiles, and the one that provides other essentials like food, clothing and shelter, is a zero sum enterprise because profits realized by being good at something are not distributed to those responsible. Instead, savings realized by rationing care and making 80-year-olds get up in the middle of the night to get to the hospital for 7 a.m. surgery are distributed as profit to those who have contributed absolutely nothing. Now, theyre going to be rewarded futher in the name of payformance and were going to be chastised as slackers.
The payformance system coming down the pike is from the same people who brought you HIPAA, JCAHO, corporate compliance and the RBRVU system. It will do nothing to control cost or reward quality. It will be inflationary and paralyze us in yet another compliance nightmare from which we cannot awaken. I cant wait for some prune-faced regulator to show up in my office and put a big C- on my front door. That should be good for business.
Dr. Cossman is the medical director of the vascular laboratory, the director of vascular trauma and the director of resident education in vascular surgery at Cedars-Sinai Medical Center in Los Angeles.
