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wo years ago, this “Practice Management” column introduced pay-for-performance (P4P) as “The Hot Health Policy Topic of 2005.” P4P has become even hotter; at a late October meeting in Washington, a speaker described some of the participants as “having their hair on fire.”

The temperature is considerably higher in the policy-making, employer- and payer-driven arena than it is in the anesthesiology department. Debates and discussions at the ASA 2006 Annual Meeting in Chicago — and within subspecialty societies — nevertheless suggest that a progress report could be useful to all of our members.

Performance Measures for Anesthesiologists

The basic units of P4P programs are, of course, the measures themselves. ASA has produced five “quality incentives” or P4P measures to date:

All but the chronic pain measure are adaptations of institutional quality measures developed by nationally recognized groups, including the Surgical Care Improvement Project (SCIP, a national partnership of public and private organizations, including ASA, formed in 2003 with the goal of improving the quality of surgery by reducing the incidence of postoperative complications), the Centers for Disease Control and Prevention, the Joint Commission on Accreditation of Healthcare Organizations and the Institute for Healthcare Improvement. Three members of ASA’s Committee on Performance and Outcomes Measurement (CPOM) represent the specialty within SCIP. The chronic pain measure was drafted by ASA’s Committee on Pain Medicine and subsequently endorsed by five additional specialty organizations representing pain physicians.

CPOM presented a P4P panel at the Annual Meeting in which Committee Chair Robert S. Lagasse, M.D., proposed additional interventions that could be the basis for potential measures:

As much examination and refinement as these measures have received and will continue to receive within our Society as well as within the pain medicine and critical care subspecialty societies, the external standardization and vetting process required by most payers is still in its early stages. Only the antibiotic prophylaxis measure has been approved for use by the Centers for Medicare & Medicaid Services (CMS), the American Medical Association (AMA) Physician Consortium on Performance Improvement (the Consortium or PCPI) and the Surgical and Ambulatory Quality Alliances (SQA, AQA). At press time, the normothermia and the critical care measures are under consideration at AMA. The roles of the numerous organizations involved in this process have changed since their names were placed before NEWSLETTER readers in 2005. Indeed some of today’s major players in Table 1 on page 29 did not exist two years ago.

Vetting Organizations: The 2006 Scorecard
First of all, why are we seeking external validation of any sort? ASA has a long and respected history of publishing evidence-based practice parameters without consulting third-party “stakeholders.” Practice guidelines do not translate automatically into performance incentives, however. The payers in particular contemplate using bonus payments and/or withholds in order to affect the practice patterns of physicians in multiple specialties at the same time. Accordingly they want a thorough and uniform validation system that will shield them from multiple versions of a given performance measure as well as from individuals’ or interest groups’ pressures or subsequent challenges, as they see it. That uniform validation process is still taking shape.

The CMS Physician Voluntary Reporting Program (PVRP)
The definitive role of CMS in accepting measures for use in the PVRP is clear. The PVRP will be very important if final Medicare physician payment legislation bases any part of the fee schedule payments on reporting measures approved by the government. (This possibility has been described in several legislative alerts on the ASA Web site.) Adoption of PVRP measures in the private sector, on the other hand, is an open question.

PVRP measures may come from and through various sources. Last year CMS decided not to include any of the three measures that ASA placed before it. In mid-October, CMS published a white paper with a list of 86 potential quality measures for 2007. Among these is a single anesthesiology measure denominated “prophylactic antibiotic timing,” which does not provide a clue as to whether the measure will be structured in such a way as to be usable by our members. If it is the same measure approved by the Consortium, it will be one that anesthesiologists can report.

The Consortium: ASA has participated in the multispecialty Consortium led by AMA for more than a decade, together with more than 100 national and state medical societies, CMS and the federal Agency for Healthcare Research and Quality (AHRQ), and experts in methodology. The Consortium has developed numerous measures relating to chronic diseases and preventive screening. The pace accelerated considerably throughout 2006 with the launch of perioperative (co-chaired by Ronald A. Gabel, M.D., who has represented ASA for more than a decade) and anesthesiology (co-chaired by Alexander A. Hannenberg, M.D.) workgroups. The result, as noted above, was adoption of a measure for the timely administration of antibiotic prophylaxis and the initiation of work on our normothermia and critical care measures.

Most specialty societies, including ASA, believe that the Consortium is the right entity to develop evidence-based clinical performance measures. CMS, however, gives equal consideration to the National Committee for Quality Assurance (NCQA, which accredits health plans) to certain specialty societies and to one disease-specific organization. Most recently CMS has awarded a contract to the Medicare Quality Improvement Organization (QIO) for Pennsylvania to create measures for specialties that have no current PVRP measures. Those of us participating in the Consortium will be interested in the extent to which QIO seeks physician involvement.

When the Consortium adopts and publishes a performance measure, CMS and most private payers “give preference to” measures sent on to the National Quality Forum (NQF) and to the AQA for endorsement and decisions on implementation.

The NQF: This large organization, of which ASA is a dues-paying member, manages an evaluation and consensus process by which its own staff, all interested members and the public endorse performance measures on the basis of their “validity, usability and importance as measures of healthcare quality.” To some extent, it is being challenged in this role by AQA.”

The AQA: “Ambulatory” in “AQA” has meant “primary care” since the organization was launched in 2005. The initial concept of AQA was to promote uniformity in the implementation of physician performance measures. Its membership therefore encompassed, from the outset, CMS, AHRQ, America’s Health Insurance Plans (AHIP) and a considerable number of individual health plans and large employers that contract with the health plans as well as the primary care and some specialty care physician organizations.

It quickly began to appear that AQA intended to choose for itself which physician performance measures would be adopted by the private payers responding to pressures from the employers to launch P4P programs. The American College of Surgeons and ASA saw an urgent need for a perioperative analogue that would either stand alone or that would turn AQA into a receptive partner, and thus was born the Surgical Quality Alliance (SQA).

The SQA: At the October meeting of AQA, both an initial set of perioperative measures — including three distinct measures for selecting, ordering and administering prophylactic antibiotics — and a set of ophthalmologic measures were unanimously adopted. Thus SQA has accomplished its mission and set the stage for further success as the unified voice of surgery and anesthesiology. Frank G. Opelka, M.D., F.A.C.S., is to be congratulated on his appointment to the AQA Steering Committee and on his brilliant leadership of a group with many interests and agendas. His presentation at the 2007 ASA Conference on Practice Management will be inspirational. The contributions of ASA SQA representatives Dr. Hannenberg, Gerald A. Maccioli, M.D., and Frank A. Rosinia, M.D., have made a real difference for ASA and our surgical colleagues.

2007 and Beyond
Anesthesiology is entering the new year with two major P4P assets: a starter set of performance measures that are gaining acceptance in the payer organizations and an even stronger reputation as a leader in improving the safety and quality of patient care. As stated by Dr. Hannenberg, “Quality improvement is part of anesthesiology’s culture. We can do well with a new generation of quality initiatives launched with our commitment to constant refinement.”

This does not obscure the fact that most anesthesiologists have yet to enjoy the “pay” component of P4P. As an organization, we are fully engaged in the arenas where the methodologies for paying for excellence or improvement in clinical performance are developing. Individual anesthesiologists and their practices also must watch for opportunities to report and to be recognized for their performance. Such opportunities are likely to appear first in the context of hospital contracts and physician-hospital organizations. (The medical director of one such organization called the Washington Office several days ago to determine the status of the quality indicators on the ASA Web site. His organization is planning to distribute annual performance rewards of up to $5,000 starting in 2008, assuming that anesthesiology benchmarks have been established and surpassed.)

Maintaining a focus on future measures also is a responsibility of ASA leadership, of the P4P team and of our members in their own practices. Some of the potential subjects for P4P incentives that are now commanding payer attention are participation in data reporting programs such as registries, where we have experience dating back to the launch of the Closed Claims Project, and (more alarming) “value,” or the cost-efficiency of care. Sharing our information and strategies has never been more important.