Measurement challenges aside, COE programs have other downsides. Strategies that displace patients from their usual site of care and regular physicians may interfere with coordination of care. They tend to be highly polarizing, dividing hospitals and surgeons into winners and losers. In alienating the latter, a price of COE programs may be lost opportunities for engaging physicians in other types of quality improvement efforts. And finally, such programs improve outcomes exclusively to the extent that they steer care away from poor performers. It provides no mechanism for helping non-COE hospitals and surgeons improve their outcomes.
PAY FOR PERFORMANCE
Another approach to improving surgical outcomes is to encourage hospitals and surgeons to provide higher-quality care with financial incentives. Both public and private payers have active pay-for-performance programs involving surgery. CMS has both a Value-Based Purchasing program aimed at hospitals and a more recent effort targeting physicians – the so-called Physician Value-Based Payment Modifier program.23 Although such programs are moving toward specialty-specific outcome-based measures (as described later), pay-for-performance programs have until now focused on adherence to evidence-based practices related to perioperative care. For example, many private payers link hospital reimbursement to process measures established by the Surgical Care Improvement Project (SCIP),24 including practices aimed at reducing rates of surgical site infection, postoperative cardiac events, venous thromboembolism, and ventilator-associated pneumonia.
Among their strengths, pay-for-performance initiatives aimed at improving compliance with specific processes of care are considerably less polarizing than selective referral. In theory, anyone can “win.” To the extent that surgeons can “play to the quiz,” process-based pay-for-performance programs have the potential to achieve rapid and significant improvements in many aspects in perioperative care. Studies in primary care suggest that pay-for-performance programs may be particularly effective in improving process compliance among poor performers and thus reducing overall variation.13,25 In surgery, evidence to date suggests similar improvements in compliance with SCIP measures.26
A more recent study by Shih et al.29 provides the most direct evaluation of the overall effects of surgical pay-for-performance programs. Focusing on coronary bypass surgery and total joint replacement, Medicare’s Premier Hospital Quality Incentive Demonstration (HQID) was intended to incentivize quality and quality improvement by increasing reimbursements to both top performing hospitals and those demonstrating the greatest degree of improvement over time.30 While mortality and complication rates for cardiac and orthopedic patients decreased significantly over time in premier hospitals, improvements of similar magnitude were observed in nonparticipating hospitals.29
In contrast to strategies led by payers and policy makers, surgeons and their professional organizations are focusing primarily on registry-based quality improvement programs.14,15,31 Their goal is to provide hospitals and surgeons with rigorous feedback about their outcomes relative to those of their peers. Some of these programs have centralized approaches to coordinating quality improvement activities, while others focus primarily on performance feedback, leaving improvement work at the local level.
The Scientific Registry of Transplant Recipients and the Adult Cardiac Surgery Database of the Society of Thoracic Surgeons were among the earliest and most recognized surgical outcome registries. The large majority of US hospitals involved in those two specialties now contribute to those databases.32,33