Lest neurosurgeons believe that the pay-for-performance bandwagon has bypassed specialists, think again. In the year since the AANS Bulletin focused on the rise of pay-for-performance programs and the attendant necessity of choosing an appropriate tool for measuring quality of care in neurosurgery, one thing seems certain: Pay for performance in some form will be visited upon neurosurgeons, and soon.
Though P4P programs have been under development for several years through organizations of healthcare purchasers such as the Leapfrog Group, the Centers for Medicare and Medicaid Services’ unequivocal endorsement of pay for performance as a way to improve quality of care and reduce healthcare costs catapulted the concept forward in 2005. The CMS not only launched P4P demonstration projects last year, but such programs, linked to Medicare reimbursement, also were approved for the 2006 budget by both chambers of the U.S. Congress and were expected to become effective Jan. 1. Though the P4P provisions were jettisoned in last minute maneuvering that resulted in a one-year freeze on Medicare reimbursement, pay for performance and specialty participation in the CMS P4P program has remained a prominent issue. A month after the budget legislation was signed, the acting chief medical officer of the CMS, Barry Straube, MD, told Modern Healthcare during the March meeting of the American Board of Medical Specialties that specialties “need to develop more performance measures faster.” He noted also that “a lot of specialties don’t have specialty-unique measures, and some are way ahead of others.”
Straube singled out the Society of Thoracic Surgeons for its leadership in developing specialty-specific quality measures. The STS has collected data on cardiothoracic surgery outcomes and quality improvement since the late 1980s and is conducting a national pilot program to measure both cost and quality. The STS discussed its 21 cardiac surgery performance measures in the Winter 2005 issue of the STS National Database News.
“The good news is that this measure set was developed largely by STS, and 15 of the 21 measures are based on data from the STS National Database,”wrote Fred H, Edwards, MD, chair of the STS Workforce on National Databases. “STS involvement in the [National Quality Forum] process has ensured that the metrics by which we measure quality were developed by cardiac surgeons, not by bureaucrats.”
Straube also recognized the American Board of Internal Medicine, which in March announced an arrangement that allows those enrolled in the ABIM’s Maintenance of Certification program to apply performance data provided though the CMS Physician Voluntary Reporting Program to the ABIM’s self-assessment of practice performance.
“This arrangement reduces redundancy,” said Christine Cassel, MD, president and CEO of the ABIM, announcing the agreement. “It permits data to be collected once, but used for multiple purposes, and provides additional incentives beyond board certification for physicians to get involved in performance assessment.”
In 2005 national organizations including the American Medical Association and the American College of Surgeons examined the CMS’ P4P initiatives and established respective sets of principles for physician participation. In December the AMA entered into a working agreement with Congress to develop 140 quality measures by the end of 2006 through the Physician Consortium for Performance Improvement, an agreement to which several specialty societies objected.
Organized neurosurgery participated in the AMA and ACS development of respective P4P principles and in June also articulated to Congress the specialty’s concerns regarding pay for performance, among them that “the program must be designed to truly improve quality of care and patient outcomes.” Organized neurosurgery also established the Quality Improvement Workgroup through the AANS/CNS Washington Committee to develop quality measures for neurosurgery.
Choosing the right tool of measurement for neurosurgery is the challenge currently facing the QIW, as well as the topic under examination in this issue of the Bulletin. Fernando G. Diaz, MD, offers an overview of P4P development and an analysis of the utility of guidelines as appropriate quality measures for neurosurgery. Robert E. Harbaugh, MD, explores the inherent weaknesses of randomized, controlled trials as the source for producing data on which useful clinical guidelines for neurosurgery can be based and turns attention to development of a procedure-specific registry as neurosurgery’s tool of choice.