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"ProvenCareSM": A Provider Driven Pay For Performance Program for Acute Episodic Cardiac Surgical Care

Alfred S Casale*, Albert Bothe, Jr.*, Ronald Paulus*, Mark Selna*, Karen McKinley*, Michael C Doll*, Scott A. Berry*, Glenn D Steele Geisinger Health System, Danville, PA

OBJECTIVE(S): To-date, "Pay-for-Performance” (P4P) strategies have addressed increasing costs, use of best-practices, and provider reimbursement incentives that pay for suboptimal outcomes, and are usually insurer-imposed and focused on primary care. Using an integrated system of clinicians, hospitals and an insurance plan, all connected by an electronic health record (EHR), we implemented a provider-driven P4P model for patients undergoing elective coronary artery bypass grafting. METHODS: Cardiovascular surgeons reviewed each of the Class I and IIa "2004 ACC/AHA Guidelines for CABG Surgery" and translated them into 45 verifiable processes. These best-practices were imbedded within a new ProvenCareSM process and “hardwired” within the EHR, orders, and “time out” procedures. All care (pre-op, in-patient and post-op), including treatment of complications within 90 days as well as rehabilitation, was packaged into a single fixed price. All elective CABG patients treated between 2/1/06 and 10/31/06 were included and compared to 143 patients treated conventionally in 2005. RESULTS: Initially, only 60% of patients had all ProvenCareSM elements met. At three months compliance with ProvenCareSM was 100% and remained above 90% through 11/06. Thirty-day outcomes improved (Table 1), with reduction in combined complications approaching statistical significance even at this early stage of the program. Mean hospital charges fell 5.2%; length of stay decreased 12%. CONCLUSION: A provider-driven P4P process for CABG can reliably deliver evidence-based ProvenCareSM that improves outcomes while lowering costs.   ProvenCare Group n = 81 % Conventional Care Group 2005 n = 143 % p Value Statistical Test Total complications 27 N/A 82 N/A 0.06 Wilcoxon's rank sum Discharged home 75 92.6 116 81.1 0.02 Chi-square Patients with any complication 24 29.6 54 37.8 0.22 Chi-square Patients receiving blood products 15 18.5 36 25.2 0.26 Chi-square Readmitted to ICU 0 0 4 2.8 0.30 Fisher's exact Pulmonary complications 2 2.5 9 6.3 0.33 Fisher's exact Operative mortality 0 0 2 1.4 0.53 Fisher's exact Atrial fibrillation 15 18.5 31 21.7 0.58 Chi-square Deep sternal wound infection 0 0 1 0.7 1.00 Fisher's exact

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