1. Welcome Ask The Experts March 24-27, 2007 New Orleans, LA

2. Pay For Performance: What Does it Mean, What will be its Impact in CV Care James Hoekstra, MD Professor and Chairman Department of Emergency Medicine Wake Forest University Health Sciences

3. CMS Core Measures and Pay for Performance Good For Cardiovascular Care? CMS Core Measures and Pay for Performance Good For Cardiovascular Care? James Hoekstra, MD Professor and Chair Department of Emergency Medicine Wake Forest University

4. Healthcare Problem/Opportunity: The Quality Gap n Quality of care and outcomes not optimal l Guideline based therapies underutilized l Outcomes not maximized n Practitioners unaware of guidelines n CQI to practitioners is slow to result in change n Hospital and patient outcomes suffer n Quality of care and outcomes not optimal l Guideline based therapies underutilized l Outcomes not maximized n Practitioners unaware of guidelines n CQI to practitioners is slow to result in change n Hospital and patient outcomes suffer

5. Symptoms – balloon inflation (min) One-year mortality (%) 6 RCTs of 1° PCI by Zwolle Group 1994 – 2001 N = 1,791 RR = 1.08 [1.01 – 1.16] for each 30 min delay (P = 0.04) P < 0.0001 12 10 8 6 4 2 0 060120180240300360 Time-delay to Treatment and Mortality in 1° Angioplasty for Acute MI: Every Minute Delay Counts DeLuca G, et al. Circulation. 2004;109:1223.

6. Average DTB over 100 minutes Despite publicizing DTB guidelines no improvement noted over 3 years 90

7. * LVEF 100 mg/dL 93% 90% 0% 20% 40% 60% 80% 100% ASABeta Blockers ACE-I or ARB* 68% Any Lipid- Lowering Agent # 87% 70% Clopidogrel Discharge Medication Use in CRUSADE (After 3 years of CQI by participating hospitals) CRUSADE: Quarter 1, 2004-Quarter 4, 2004 (n=39,933)

8. Why P4P(pay for performance) with CMS? >60% Annual Hospital Revenue from Medicare/Medicaid

9. With a Relatively Fixed $ Pool, CMS recognizes…. 95% increase in beneficiaries vs 40% reduction in # workers Years 2000 – 2030. “Why Should We Pay For Poor Quality?”

10. “Voluntary” Reporting of Hospital Core Measures Performance n Core measures performance reporting mandated for AMI, HF, Pneumonia, CABG, Hip and Knee Surgery. n Public reporting of hospital “scorecards” on core measure data in 5 areas by CMS l Marketing and reputation at stake n Hospitals scramble to develop core measures reporting methods and improve core measures performance n Core measures performance reporting mandated for AMI, HF, Pneumonia, CABG, Hip and Knee Surgery. n Public reporting of hospital “scorecards” on core measure data in 5 areas by CMS l Marketing and reputation at stake n Hospitals scramble to develop core measures reporting methods and improve core measures performance

11. Hospital AMI Core Measures – Initial Release 2002 AMI-1 Aspirin at arrival AMI-2 Aspirin prescribed at discharge AMI-3 ACEI for LVSD AMI-4 Adult smoking cessation advice/counseling AMI-5 Beta blocker prescribed at discharge AMI-6 Beta blocker at arrival AMI-7 Time to thrombolysis AMI-8 Time to PTCA AMI-9 Inpatient mortality Acute Myocardial Infarction (AMI) Core Measure Set

12. $ $ $ $ 100% 90% 80% 70% 60% 50% 40% 30% 20% 0% +2%Bonus +1%Bonus +2% Bonus +1% Bonus -1% Reduction -2% Reduction Quality: Five Clinical Areas 1.Coronary artery bypass surgery 2.Heart attack 3.Heart failure 4.Hip and Knee replacements 5.Pneumonia CMS Pay For Performance Demonstration Project The Week in HealthCare, Jeff Tieman, July 14, 2003 10% Years 1 & 2- 2004-2005 Year 3-2006

14. The New England Journal of Medicine Editorial on February 1, 2007

15. Issues with Pay for Performance n Is there adequate data on core measures?? l Linked to outcome? l Definitions? l Able to measure accurately? n Reporting system factors l ICD-9 code criteria vs clinical criteria l Risk/Comorbidity adjustment n Is there adequate data on core measures?? l Linked to outcome? l Definitions? l Able to measure accurately? n Reporting system factors l ICD-9 code criteria vs clinical criteria l Risk/Comorbidity adjustment

16. Unmet Needs of Present Pay for Performance Program n Retrospective Data Gathering l Labor Intensive l Missing Data l Missing Exclusions n No CQI Feedback Loop l Link to physicians l Delay to feedback/education n No Real-Time Data Entry n Retrospective Data Gathering l Labor Intensive l Missing Data l Missing Exclusions n No CQI Feedback Loop l Link to physicians l Delay to feedback/education n No Real-Time Data Entry

17. What’s Coming? Do I Hear a Train? n Additions and changes to core measures n New diagnoses/processes n Patient follow up, outcomes n Risk adjustment n Physician Pay for Performance! l July, 2007 1.5% n Additions and changes to core measures n New diagnoses/processes n Patient follow up, outcomes n Risk adjustment n Physician Pay for Performance! l July, 2007 1.5%

18. Question&Answer

19. Thank You! Please make sure to hand in your evaluation and pick up a ClinicalTrialResults.org flash drive