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July 1, 2013 Volume 77, Number 7
Administrative Update: Quality, Value and ASA Norman A. Cohen, M.D. ASA Vice President for Professional Affairs


Memorials and Monuments
As I began writing this column, my wife and I were in our nation’s capital. Taking advantage of a beautiful spring Saturday, we walked past the White House and among the memorials and monuments on the Mall and nearby. We saw the memorials to those who fought and died in the wars of the 20th century, to our presidents who led us through major turning points in our nation’s history, and to Martin Luther King, who helped our country right the wrongs of racial segregation.

Our greatest leaders not only had deep understanding of the world in which they lived, they also had a clear vision of the world as they wished it to be – a new country free to create its own destiny, a union united in which all men who were created equal could live as equals, and a country safe from the threats of murderous dictators.

Patients and Perceptions
So what does a patriotic stroll in the District have to do with anesthesiology and ASA? Our ASA presidents and other elected officers similarly strive to address the challenges of the now while navigating toward a desired future for our members and our patients. Former ASA President Roger Litwiller, M.D. (2004) spoke eloquently about the principle guiding him in these efforts as he led the Society: “It’s all about the patient because we have no other reason to exist.” I have no doubt that this beacon still guides your current officers, Board and House. Our tendency to describe what we do as “putting the patient to sleep” understates the risks and misrepresents our job. I have heard more than a few ASA leaders describe what we do as creating an artificial coma, allowing our surgical colleagues to assault our patients with knives, hammers and other tools, and then bringing our patients back to consciousness with minimal damage done to their long-term health. That’s a far cry from “going to sleep” and better describes the active and essential role we play in patient care. What we do is neither simple nor as safe as we often encourage the public to believe.

Quality
As physicians, we use our medical knowledge, experience, technical skills and understanding of the surgical requirements and needs of our patients to craft an anesthetic. We do this with careful attention to safety and an aspiration to achieve the highest quality. It is indeed all about the patient.

But how do we know if we have succeeded? Is it enough that the patient is alive when we stop the anesthesia clock? That they have no fewer teeth? That they have not suffered awareness or nausea? Or should we delve deeper and look for lung injury, immune modulation or cognitive dysfunction? When are these consequences our sole responsibility, a shared responsibility or the responsibility of others?

The pursuit of health care quality is a never-ending process of improving what we do to achieve the goal of returning the patient to the best possible state of health. To do this requires us to measure what we do, identify what works and what does not in achieving our goal, and to change what we can influence based both on these findings and the introduction of new knowledge. Wash ... rinse ... repeat ...

These steps are nothing new for anesthesiologists, but, like it or not, quality data is now being used for much more than altruistically improving care.

The Value Movement
The pay-for-value movement is driving reform in health system delivery. Insurers are increasingly paying us based on clinical and economic outcomes rather than on simply the volume of services we render. And they are doing this often using fairly crude performance measures, most of which look only at processes of care. These profound payment changes require each of us to take stock of where and how anesthesiologists can make a difference in value-driven health care. To succeed in such a system, we must have the ability to fairly, transparently, completely and accurately measure our performance across all domains.

Decisions we make in caring for our patients impact surgical outcomes. Glycemic management, fluid strategies, transfusion decisions, pain interventions, choice of anesthetic technique and preoperative optimizations are but a few of the factors that impact length of stay, surgical complications, and overall mortality and morbidity. Determining our contributions in these areas is more difficult than determining traditional measures of anesthesia mortality and morbidity, but such determination is essential, requiring nuanced perspectives on measurement and attribution.

Where We are in Value-based Payment
Publicly available measures of importance to anesthesiology typically evaluate how well we followed a protocol believed to be associated with improved patient outcomes. As some recent studies have shown, these processes may not always result in actual outcome improvement.1

The Physician Quality Reporting System (PQRS) is a Medicare value-based payment approach designed to incentivize measurement and reporting of quality of care. The fairly small payments initially earned for successfully participating are becoming payment reductions for those physicians and others who do not engage. While there are currently more than 300 measures in the PQRS program, only a few are applicable to most anesthesiologists. The measure set focuses on screening and medical management for chronic diseases, high-cost and high-frequency infections, cancer detection and a number of surgical conditions. You can find out more information at www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html.

Other programs that include clinical quality measures, such as the Electronic Health Record incentive program and the several Accountable Care Organization (ACO) initiatives, essentially have no measures applicable to our specialty. Again, our contributions are given short shrift.

While the focus on reducing admissions and avoiding unnecessary procedures is a laudable goal, the failure to provide equal attention to quality improvement in the perioperative phase ignores the massive opportunity for driving value improvement in this high-cost, high-risk, high-opportunity care arena. Patients will continue to have heart surgery, joint replacements, cancer surgery and many other procedures, no matter how well an ACO manages and coordinates care.

We currently have few measures in part because the measure endorsement process is complex and bureaucratic and in part because we work in a team setting, making attribution at the individual level very difficult. Also, a relatively small specialty such as ours has great challenges successfully engaging when our focus (perioperative care) is orthogonal to the priority areas for the endorsing bodies.

Where We Need to Be
Quality and outcomes will increasingly drive payment. Current discussions in Congress about a permanent Sustainable Growth Rate fix make this exquisitely clear. The technical work we do in the procedural suite will remain a component, but “base + time + outcome” or some variant has already begun to replace our revered and time-tested Relative Value Guide™ payment formula. The greater the responsibility we assume for perioperative outcomes, the greater the opportunity for our specialty to survive and thrive in this new paradigm. Frankly, this is the driving force behind the ASA Perioperative Surgical Home model of care.

ASA has led the way for many years in helping our members improve quality through developing rigorous evidence-informed standards and guidelines, educational initiatives, producing quality monitoring tools, creating and funding the Anesthesia Quality Institute (AQI) and its NACOR registry, and advocating on behalf of our patients and members with regulatory and legislative bodies. These efforts will continue, will accelerate and will be better integrated with our strategic goals.

Cause for Optimism
Recent events make me optimistic. We are in the early stages of developing new performance measures addressing team-based care with a key surgical stakeholder; furthermore, we are jointly evaluating expansion of our ASA Consultation Program with our surgical and perioperative nursing colleagues. Our Committee on Performance Outcomes and Measurement (CPOM) is creatively exploring better and more meaningful measures of anesthesia outcomes. We have a reorganized and much better-staffed regulatory and legislative advocacy group under our newly named Chief Advocacy Officer, Manuel Bonilla. Early indications are that new CMS registry requirements will offer greater flexibility for specialty-developed measures – making AQI even more relevant and CPOM’s work timelier. We have a Health Policy Research operation plan in place, led by Tom Miller, Ph.D., M.B.A. We are rapidly refining the specifics of an anesthesiology-relevant alternative delivery and payment model, our ASA Perioperative Surgical Home model. Our physician experts and education staff will be introducing a new quality educational activity later this year. And we have an ASA staff working together better than ever under new CEO Paul Pomerantz.

The infrastructure is in place, our strategic plan is sound and we have the passion of our members. We can shape a better future for our specialty. We just need to remain committed to our principles and envision the future as we want it to be.



Norman A. Cohen, M.D. is Associate Professor of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, Portland.

Reference:
1. Hawn MT. Timing of Surgical Antibiotic Prophylaxis and the Risk of Surgical Site Infection. JAMA. Surg 2013; 1.