Since the 1999 release of the Institute of Medicine’s influential report, To Err Is Human, a number of initiatives intended to reduce errors and improve quality of care have percolated through the medical community. This increased emphasis on the formalization of quality and accountability processes was brought to the attention of specialists in March 2000, when the American Board of Medical Specialties voted to transition recertification programs to maintenance of certification programs.
Neurosurgeons turned their attention to these processes in 2002 when their certifying board, the American Board of Neurological Surgery, announced its own plan for implementing MOC. The ABNS has continued to develop its program, honing its methods for defining competency in the four MOC components — professional standing, lifelong learning, cognitive experience, and practice performance — and in January 2006 the ABNS will begin tracking continuing medical education credit for neurosurgeons certified in 1999 and thereafter.
While the MOC program was evolving, a trend toward linking quality initiatives to physician payment — the proverbial carrot rather than stick — was gaining momentum. Some of these so-called pay-for-performance, or P4P, programs have borrowed from well-known business models, such as the Six Sigma data-driven methodology for quantifying quality and the International Organization for Standardization guidelines for development of technical standards. In November 2000 a consortium of Fortune 500 companies and other health benefits providers known as The Leapfrog Group launched operations with a mission of improving safety, quality and affordability of healthcare through incentives and rewards. The group rates hospitals based on quality and safety practices and posts results, which are available to the public, on its Web site; in addition, consortium members agree to follow the group’s “purchasing principles.” According to Leapfrog estimates, more than half the U.S. population was in a Leapfrog region in 2004, and implementation of the group’s first three recommended quality and safety measures could save $50 billion annually.
The P4P issue heated up for physicians in February 2005 when the Centers for Medicare and Medicaid announced the Physician Group Practice Demonstration, a three-year P4P program for 10 large physician practices. The CMS cited evidence of reduced healthcare cost in the private sector, in addition to better quality, as incentives for the program’s development. Then the March 2005 report to Congress by the Medicare Payment Advisory Commission put P4P on the front burner for physicians by including specialists like neurosurgeons in the P4P mix. If Congress accepts MedPAC’s recommendations, neurosurgeons who participate in Medicare could become P4P participants as early as January 2006. Also in March:
- the American Medical Association released P4P principles and guidelines designed to help physicians determine whether a program is fair and ethical;
- the Medical Group Management Association issued a statement in support of MedPAC’s recommendation, albeit with some reservations; and
- the American Medical Group Association launched its own P4P initiative, which involves a steering committee of healthcare leaders — among them Uwe Reinhardt, PhD, and John Wennberg, MD — whose mandate it is to “totally overhaul the process of reimbursement by linking it directly to attainment of quality performance and outcome measures.”
Why should neurosurgeons care? Given the recent convergence of the pay-for-performance and maintenance of certification initiatives, it seems that neurosurgery has a rather large stake in successful development of meaningful quality measures. What these measures will be is the burning question which two authors will explore in the following pages. Other authors delve into the P4P topic, providing historical, legislative, and management perspectives that elucidateits pitfalls and possibilities for neurosurgery.