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Ann Thorac Surg 2005;80:387-395
© 2005 The Society of Thoracic Surgeons

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Presidential address

Quality, Safety, and Transparency: A Rising Tide Floats All Boats

Division of General Thoracic Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota

^_* Address reprint requests to Dr Pairolero, Division of General Thoracic Surgery, Mayo Clinic College of Medicine, Rochester, MN 55905 (Email: pairolero.peter{at}mayo.edu).

	Introduction

Top Introduction Introduction Quality and Safety Pay-for-Performance Government Relations Summary Footnotes References

 
I am deeply grateful for the honor and privilege of serving this past year as the 39th President of The Society of Thoracic Surgeons. This is indeed the highest honor of my career, and I am very humbled by this extraordinary privilege. I am also grateful for the opportunity to have worked so closely with so many of you on so many issues facing the Society this past year. Serving as your President has demonstrated that a team of well-organized thoracic surgeons working intimately with our Society’s Chicago and Washington, DC office staff can effectively meet the many challenges of an increasingly complex health care environment. Everything that we have achieved is directly due to the energetic and dedicated teamwork of both volunteer membership and the Society staff.

Throughout our careers each of us has been influenced by individuals who have made a significant difference in our lives, and many of us have been privileged to stand on the shoulders of giants. I put myself into this category, and for this reason I wish to acknowledge those individuals who have profoundly influenced my life and career as a thoracic surgeon.

My parents, Peter and Louise Pairolero, in addition to providing all the necessary attributes throughout childhood, made it possible, in times that were far less prosperous than today, for me to leave the economically depressed upper peninsula of Michigan and complete my undergraduate and medical education without economic debt. For this I will always be grateful.

In high school, I was influenced to choose medicine as a career by a young man from my hometown, Roger Neault, who was a senior medical student at the University of Michigan. Dr Neault served as a mentor throughout my education, and I eventually followed him to Mayo Clinic where he was a staff ophthalmologist.

At Mayo Clinic, I had the privilege of working in the laboratory of our 13th President of The Society of Thoracic Surgeons (STS), Dr F. Henry Ellis, where we studied the effect of infarctectomy in the treatment of myocardial infarction. It was Dr Ellis who mentored me into thoracic surgery. During my residency I came under the spell of Dr Dwight McGoon, whose scholarly and uncompromising approach to congenital heart surgery taught me the details of complex technical surgery. But it was Dr O. Theron "Jim" Clagett who convinced me to become a general thoracic surgeon.

In 1973, vascular surgery was a component of cardiovascular surgery, and the surgeons at Mayo Clinic suggested that I work with Dr. E. Stanley Crawford in Houston, Texas. It was with Dr Crawford that I learned that anything was possible if one was willing to work to achieve it.

I have been associated with a number of outstanding colleagues at Mayo Clinic over the 31 years that I have been on staff, far too numerous to mention individually. Nonetheless, my tenure as President of The Society of Thoracic Surgeons would not have been possible without the support of the general thoracic surgery team at Mayo Clinic and my current colleagues in the Division of General Thoracic Surgery, Dr Mark Allen, Dr Claude Deschamps, Dr Francis Nichols, and Dr Stephen Cassivi.

Finally, I would particularly like to thank my wife and best friend, BJ, and my 2 children, Peter and Steven, for their support and understanding during the past years.

	Introduction

Top Introduction Introduction Quality and Safety Pay-for-Performance Government Relations Summary Footnotes References

 
Fifty years ago, doctors were still making house calls, professional fees and hospital costs were low, medical insurance was limited to a small segment of the population, and the alphabet soup of medical jargon did not exist. However, thoracic surgery was about to be catapulted into a new era by events in Minnesota. In 1955 only two centers in the world were performing open-heart surgery with cardiopulmonary bypass on a regular basis, John Kirklin, MD at Mayo Clinic in Rochester, and C. Walton Lillehei, MD, just 90 miles north at the University of Minnesota in Minneapolis. On May 18, 1955, Dr Kirklin reported that 4 of his initial 8 patients repaired with this technique survived [1], and the new age of cardiopulmonary bypass was established. This year on May 12 Mayo Clinic celebrates the 50th anniversary of this event.

Thoracic surgery is a discipline that was both invented and matured in the 20th century. Its development parallels the unprecedented advance of scientific knowledge that has become the hallmark of our times. However, at the dawn of the 21st century, thoracic surgery is increasingly being shaped by profound social and political changes in our everyday way of life.

My purpose today is to describe how these external forces have interacted with our profession to produce the myriad of quality and safety changes that we see around us. I will divide my efforts into three segments. First, I will describe how quality and safety has influenced our specialty. Second, because quality and safety is transparent and available for all to see, I will discuss the effects of transparency on reimbursement. Lastly, and most importantly, I will discuss what we must do to grow stronger in response to these changes.

	Quality and Safety

Top Introduction Introduction Quality and Safety Pay-for-Performance Government Relations Summary Footnotes References

 
In 1990 the Institute of Medicine (IOM), a congressionally chartered independent organization to improve health care, defined health care quality as "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge" [2]. Although this definition may seem intuitive to most of us, the words were carefully chosen and have been interpreted by many to have broad implications for society at large. However this definition has withstood the test of time and is widely accepted today.

Over the years, numerous reports have suggested that the United States health care delivery system did not provide consistent, high-quality care to all people. All too often Americans did not fully benefit from the therapy provided, and in many instances patients were harmed. Nearly a decade later, in 1999, the IOM released its first in-depth report on health care, To Err is Human: Building a Safer Health System [3]. This report described three components of health care quality, ie, (1) safety, (2) up-to-date clinical practice, and (3) patient satisfaction, and pointed out that these quality components are continuously influenced by the external forces of regulatory activities and marketplace incentives. Now, 6 years later, you cannot help but notice that much of medicine revolves around both safety and clinical practice and their interaction with regulatory activities. Today, however, patient satisfaction and marketplace incentives have not reached the same level of scrutiny as safety and clinical care, but we must be prepared to deal with them also as they are just around the corner.

Allow me to illustrate. To Err is Human [3] took aim at medical errors and defined them as "the failure of a planned action to be completed as intended or the use of a wrong plan to achieve a specific aim" (p 21). As we have come to learn, this report concluded that medical errors were responsible for tens of thousands of Americans dying each year and hundreds of thousands more being injured. Yet the majority of these medical errors did not result from incompetent health care providers, but rather from faulty systems and processes that allowed individuals to make mistakes rather than prevent them from occurring. To Err is Human [3] concluded that these mistakes could only be prevented by a total redesign of the health system that would make it easier for individuals to do the right thing and more difficult to do the wrong thing.

To achieve a better safety record across our country, the IOM recommended a four-tiered approach that included:

1 Establishing a national safety knowledge base.

2 Developing a mandatory national reporting system.

3 Raising safety performance standards through oversight organizations, professional groups, and purchasers of health care.

4 Implementing safety systems in all health care organizations.

The response to this first report was swift and supportive from both public and private sector leaders. Congress acted immediately and created the Agency for Healthcare Research and Quality (AHRQ) to improve quality, safety, and effectiveness of health care for all Americans [4]. The National Quality Forum (NQF), a private not-for-profit corporation, was also formed in 1999 to develop and implement a national strategy for health care quality measurement and reporting [5]. The Leapfrog Group, an association of private and public group purchasers of health care created in 2000, followed suit [6]. Leapfrog unveiled a market-based strategy to improve quality and reduce medical errors by implementing three perceived best practices. These included the use of computerized physician-order systems, the staffing of intensive care units with physicians credentialed in critical care medicine, and the development of an evidence-based hospital referral system. Today, Leapfrog has increased this number to 30 by incorporating all of the NQF’s patient safety practices that are intended to reduce the risk of harm resulting from processes, systems, or environments of care [7].

Congress then required all state governments to collect standardized information about adverse medical events resulting in death and serious harm. Hospitals were required to begin reporting first, but eventually reporting had to be done by other health care organizations as well. Currently, only one-third of the states have responded to this congressional mandate by creating reporting requirements, and my home state, Minnesota, is leading the way. In 2002 the legislature of the State of Minnesota mandated reporting of all 27 "never-events" that the NQF said should never occur in a hospital [8, 9]. Eight of these "never-events" directly involve the practice of surgery, five specifically as surgical events, and three as device events (Table 1). Today in Minnesota reports of these eight "never-events" are available for everyone to see.

Are we there? Certainly not yet, and most likely this vision is still a few years away. But a ground swell has developed, and it is beginning to surround us. Soon this rising tide will be a sea of up-to-date clinical practice, safety, and patient satisfaction activities. And this sea, like a rising tide, will float all boats. As individuals we can choose to get on board or not, but thoracic surgery as a specialty will rise to this occasion. Not only will we meet this challenge, we will, in fact, lead the way, because this is what our heritage of innovation and leadership from the last century has taught us. This is our destiny.

No longer is it good enough to say that we are the best. The evidence must demonstrate that we are the best. We must recognize that performing at high levels of quality and safety is a science and not an art. We must become as proficient in the science of quality and safety as we are in the art of medicine and surgery. To develop such a culture of quality and safety, all of us must become committed and engaged. We must be vigilant about the potential for failure, and we must develop an environment that expects and rewards critical evaluation of processes and outcomes. To achieve this, we must critically examine, improve, and standardize processes. We must acknowledge that no longer is it possible to have multiple and individual ways of accomplishing the same thing; we must learn from each other and spread best practices. We must recognize that multiple pathways are inefficient and lead to waste and medical errors.

To attain this type of health system will require changing the structures and processes of the environment in which health care functions. The delivery of health care will need to be evidence-based; information technology will have to be embraced; medical payment will have to be aligned with quality and safety improvement; and the culture of the workforce will have to change. And, my fellow members, this is and will continue to happen, and thoracic surgery will be there leading the way just as we did with our National Database (NDB) 16 years ago.

The report, To Err is Human [3], asked medical societies to make improvements in quality and safety by setting their own performance standards and incorporating them into their educational programs (p 20). Among all specialty societies, The Society of Thoracic Surgeons is leading the way in this effort. Our NDB, which was established in 1989, is the largest database of any medical society today. Now, in addition to adult cardiac surgery, it also includes congenital heart surgery and general thoracic surgery. Our NDB is recognized by federal, state, and private agencies as the gold standard for quality and safety, and it has been used by them as a platform for quality improvement. In 2000 our Society was awarded a 3-year $1,500,000 grant from AHRQ to evaluate the effect of data management on improving cardiac surgery outcomes. The money was well spent! Over the years our NDB demonstrated that survival outcomes were best when coronary artery bypass patients received preoperative beta-blockers and patients greater than age 75 were bypassed with internal mammary artery grafts [11, 12]. Even more important, when these findings were made known to our members through a continuous quality improvement feedback loop, we were able to demonstrate in a national randomized trial that our members participating in our NDB converted to this technique [13]. These results have been published and are available for all to see. Our Society was the first medical specialty society to receive an AHRQ grant, and because we were successful in demonstrating quality improvements we were awarded a 3-year $1,500,000 renewal in 2003 to evaluate the durability of coronary artery bypass surgery.

Our Council on Health Policy and Relationships, through our STS Washington, DC office has been very active in advancing political change. In March 2003, the House of Representatives passed the Patient Safety Act of 2003 (House of Representatives [HR] 663) by a nearly unanimous bipartisan vote of 418 to 6. Unfortunately the Senate’s version of this bill (Senate [S] 720), the Patient Safety and Quality Improvement Act, languished in the Committee until July 2004. Last summer the Senate by unanimous consent approved an amended version of the House of Representatives’ bill (HR 663 as amended by S 720). However, major differences existed between the two versions of this bill. Our Washington, DC staff, working with senior White House, Senate, and House staff, attempted to resolve these differences in time to send a bipartisan bill to the President’s desk before the end of the 108th Congress. Unfortunately, the differences could not be resolved and it will remain for the 109th Congress to pass this bill. In the interim, The STS will continue to work tirelessly in its efforts to have President George W. Bush sign the Patient Safety and Quality Improvement Act into law.

This bill provides the legal framework through which patient safety organizations can voluntarily and confidentially collect data from providers regarding medical errors without the concerns of the Health Insurance Portability and Accountability Act regulations and, most importantly, the fear of litigation. These safety organizations can then analyze the data and suggest changes to prevent future harm to patients. These changes almost certainly will be transparent for all to see. Many groups will become patient safety organizations, and as a medical organization our Society must become one too. Becoming a patient safety organization will provide added protection to the data in our NDB and will improve the care of our patients. This is the next step in the evolution of our NDB, and we will lead the way.

Setting, reporting, and enforcing performance standards for quality and safety through various external agencies, such as accreditation and certification are also occurring. The Joint Commission on Accreditation of Healthcare Organizations, already charged for the last 50 years to continuously improve the quality and safety of patient care, immediately took up the IOM’s recommendations. New standards for patient identification, drug ordering and administration, and avoiding wrong-site surgery were instituted. Marking the correct site of surgery by the patients themselves and the pause before making an incision have become new and commonplace occurrences. Since July 2002, the Joint Commission has required all accredited hospitals to collect and submit performance measures on acute myocardial infarction and heart failure through their new web-based initiative, ORYX^® [14].

Up-to-date clinical practice is the second component of quality identified by the IOM. To achieve this goal, the American Board of Medical Specialties, the umbrella board for certification of all physicians, has developed a Maintenance of Certification^© program aimed at ensuring that all board-certified physicians in the United States continuously meet the highest standards of patient care and accountability throughout their careers [15]. Although not yet fully implemented, all 24 member boards of the American Board of Medical Specialties, including the American Board of Thoracic Surgery, have committed to Maintenance of Certification^©, and we will be seeing the implementation of this program in the near future.

Maintenance of Certification^© moves from a recertification process with cognitive testing every 6 to 10 years to a continuous process with ongoing evaluation. This new program will evaluate four components of physician practice: (1) professional standing, (2) cognitive expertise, (3) lifelong learning and self-assessment, and (4) practice performance. This will be a continuous process of assessment and improvement with one component being evaluated every several years over the course of the physician’s career. Maintenance of Certification^© will focus on six general competencies integral to quality care by physicians: (1) patient care, (2) medical knowledge, (3) practice-based learning and improvement, (4) communication skills, (5) professionalism, and (6) systems-based practice. Our NDB is in an ideal position to interact with the American Board of Thoracic Surgery in evaluating practice performance, practice-based learning, and systems-based practice. Will we accept these new certifying requirements? I contend that we must accept them, for they will improve the quality of care we provide our patients.

Finally, I already mentioned that the IOM’s third determinant of quality, patient satisfaction, is just around the corner. In July 2002, the Centers for Medicare and Medicaid Services (CMS) in collaboration with the AHRQ developed the Hospital Consumer Assessment of Health Plans or Hospital CAHPS^®, an initiative that focuses on measuring and reporting patient experiences with inpatient care [16]. Hospital CAHPS^® is a patient satisfaction survey instrument that queries hospitalized patients regarding communication from doctors and nurses, education about medications, effectiveness of pain control, discharge information, and the hospital environment. The intent is to help consumers make better informed choices among hospitals and create incentives for hospitals to improve performance. For the past 3 years this survey instrument has undergone evaluation in selected hospital centers around the country, and the survey instrument is now close to distribution. The CMS has mandated that Hospital CAHPS^® be implemented in the summer of 2005 [17]. This initial effort will require hospitals to survey and report their performance for three conditions: (1) acute myocardial infarction, (2) heart failure, and (3) pneumonia. How this information will be utilized has not yet been announced, but I am sure we will hear much more about this initiative in the months ahead. In addition, as with quality and safety, we must also be prepared to lead here.

	Pay-for-Performance

Top Introduction Introduction Quality and Safety Pay-for-Performance Government Relations Summary Footnotes References

 
The Institute of Medicine’s report, Crossing the Quality Chasm [10] stated that, "The goals of any payment method should be to reward high-quality care and to permit the development of more effective ways of delivering care to improve the value obtained for the resource expended" (p 181).

This statement foreshadowed the concept of "pay-for-performance" (P4P), which arguably was coined in California in 2002 by the Integrative HealthCare Association. However, other payers such as Wellpoint Health Networks, one of the largest providers of Blue Cross and Blue Shield health plans, and HealthPartners (a Minnesota based payer), have had their own equivalent payment plan since the mid 1990s. The intent of all these plans is to incentivize and reward excellence in physician group medical care and hospital outcomes. The problem is that these programs are arbitrarily applied to all patients and are not risk stratified. Nor do they take into consideration patient noncompliance. What happens if the sickest patients fail to follow the best medical recommendations possible? How will performance be judged? How will P4P be funded? Will new funds be added to pay for quality or will funding be taken from those who fail to demonstrate quality improvement? I suspect the latter.

HealthPartners is providing an early answer to the funding question. As of January 1, 2005, HealthPartners will no longer pay for surgical procedures performed on the wrong patient, performed on the wrong site, or associated with an unintended retained foreign body [18]. These three errors are among the 27 "never-events" that the state of Minnesota said should never occur in a hospital and are part of a mandatory reporting program. HealthPartners is the first payer in the nation to announce withholding payment for these types of medical errors, although few hospitals or physicians have ever charged or been paid for these errors. Nonetheless, HealthPartners, by drawing a line in the sand that was never there before, has now set a seminal precedent.

Although these P4P concerns have not been fully vetted, the wave is still heading toward shore. Since 2002, more than 35 health plans covering more than 30 million individual lives have begun some type of program that was developed to link doctor bonuses to performance [19]. In 2005 this number is expected to more than double. General Electric Co and Ford Motor Co are expanding a program called Bridges to Excellence that pays bonuses for treating diabetes and cardiac patients "correctly" [19].

Similar events are occurring in Washington, DC. In June 2003, the Medicare Payment Advisory Commission reported to Congress that Medicare should take a lead role in adopting P4P strategies. By October 2003, the Centers for Medicare and Medicaid Services, in collaboration with the Premier nationwide hospital alliance, launched a 3-year P4P Hospital Quality Incentive Demonstration Project [20]. When this project is complete, quality data from participating hospitals will be made available to all health care professionals and consumers through a variety of channels, including the CMS website. Five clinical areas have been selected and three are specific to our specialty: (1) coronary artery bypass grafting, (2) acute myocardial infarction, and (3) heart failure. Thus far, 278 hospitals have enrolled in this project.

In the CMS and Premier project, hospitals will be scored on quality measures selected from a variety of different sources related to each condition. Rewarding overall performance, however, requires a valid and reliable method by which results can be aggregated and used for comparison. The composite quality score, based on a model developed by the Rhode Island Public Reporting Program for Health Care Services, is the methodology most payers are using [21]. This model deals almost entirely with clinical guidelines and the frequency with which they are followed, the assumption being that by following these guidelines, quality and safety will improve by avoiding errors of omission. In the CMS and Premier project, eight performance measures for coronary artery bypass surgery were selected, which include five guidelines and three clinical outcomes. The percent of patients in each category is then used to determine a composite score for comparison with other hospitals, and those hospitals with the highest score will receive larger Medicare payments.

Hospitals in the top 10% will receive a 2% bonus and those in the second 10% will receive a 1% bonus. All other hospitals in the top 50% will be publicly recognized for their quality but will receive no bonus. However, by the third year of this project all hospitals that fail to show improved performance beyond the bottom 20% minimum threshold established in the first year will receive a payment reduction. Hospitals in the bottom 10% will receive a 2% reduction and those in the second 10% will receive a 1% reduction. By reducing Medicare payments to hospitals in the bottom of the ranking, quality in these hospitals will either have to improve or the service will have to be eliminated. This is also a glimpse of how CMS intends to subsidize P4P. Unless additional funding is authorized to Medicare by Congress, which seems unlikely, CMS will continue to function within the concept of budget neutrality, and funds will have to come from reducing payments to those who fail to demonstrate improvement.

Although the CMS and Premier demonstration program is currently a pilot, CMS has stated that, if successful, this methodology will become a permanent Medicare program and will be applied to all hospitals. Moreover, CMS Administrator, Mark McClellan, MD, PhD, projects that in the next 5 to 10 years P4P could account for 20% to 30% of what the federal government pays providers [19]. Finally, during the 108th Congress, both the House of Representatives and the Senate introduced legislation dealing with P4P (HR 4880, S 1148, and S 2562). Although bipartisan support for this concept in Congress was good, none of the bills ever made it out of Committee because of uncertainty as to how to finance them.

Because of the problems associated with P4P, our Council on Health Policy and Relationships has been in discussion with members of Congress regarding an alternative concept to P4P. We believe that the results of our AHRQ grants that I previously discussed demonstrate that quality improvement can be achieved by participating in our NDB, and we have proposed the alternative concept of "pay-for-participation." Participation in a clinical outcomes program, such as our NDB, would reduce the problems associated with risk stratification and patient noncompliance, whereas at the same time it would enhance quality and safety through continuous quality improvement. We have had discussions with the House of Representatives Ways and Means Health Subcommittee Chair, Representative Nancy Johnson (Independent, CT), as well as the Senate Finance Committee ranking Democrat, Senator Max Baucus (Democrat, MT), regarding both P4P and pay-for-participation. The STS leaders and staff have also met with the director of the Center for Medicare Management, Herb Kuhn, and the director of the Office of Clinical Standards and Quality, Sean Tunis, MD, to discuss the Society’s NDB and the possibility of partnering with CMS to reward participants by providing additional payment for quality improvement. Although this STS initiative is in its infancy, it is a new concept that could reduce the impact of Medicare payment reductions for our members who participate in our NDB. It is a concept that we will continue to actively pursue in the coming year.

As I have already mentioned, rewarding overall performance requires a valid and reliable method by which quality results can be aggregated and used for comparison. A variation of the CMS and Premier demonstration project has been developed by the NQF in collaboration with our Society. One of the strategic goals of the NQF is to have NQF-endorsed standards become the primary standards to measure the quality of health care in the United States. To this end, the NQF recently released its National Voluntary Consensus Standards for Cardiac Surgery, which is a set of 21 performance measures for evaluating structure, processes, and outcomes that are linked to quality of care for cardiac surgery [22]. Members of our Society were at the NQF providing input to the discussions leading to the selection of these measures. Both Dr Jeffrey Rich and Dr Frederick Grover are members of the NQF Steering Committee, and Dr T. Bruce Ferguson is the Chair of their Technical Advisory Panel. As a result of The STS involvement, 15 of the 21 performance measures are proprietary measures from our NDB. As part of our commitment with the NQF, The STS has also agreed to allow access to our risk algorithm model for morbidity and mortality through an STS-sponsored website. This website will allow hospitals or surgical groups to derive their mean morbidity and mortality and compare them with our NDB benchmarks. Another great benefit of this website to both surgeons and patients alike is that a particular patient’s risk profile for death and major complications can be generated in real time and shared with the patient during the preoperative discussion of the risks of surgery.

These 21 cardiac performance measures had been previously approved by more than 200 consumer groups, professional associations, health care systems, federal agencies, and quality improvement organizations. Because these performance measures are now NQF-endorsed, these approving organizations, including CMS, are obligated to use them in their continuous quality improvement programs. This is extremely important because NQF endorsement precludes these approving organizations from developing practice performance measures from their own or other databases, as was done in the CMS and Premier demonstration project.

All of these practice performance measurements are within the control of the cardiac surgeon. All are patient-centered and address the remaining five major areas for quality improvement spelled out by the report, Crossing the Quality Chasm, namely, safety, effectiveness, timeliness, efficiency, and equity [10]. These voluntary consensus standards will promote the highest quality of care for our patients. By releasing these measures to the public and all interested parties, consumers of health care will be able to select providers on evidence-based performance.

During the past few years, evidence-based practice guidelines have also become commonplace in medicine, and our Society recently inaugurated a practice guideline series with the publication of its first guideline, "Transmyocardial Laser Revascualization," in the Annals of Thoracic Surgery [23]. The intent of these guidelines is to serve as an unbiased clinical guide for thoracic surgeons. By combining these guidelines with the practice performance measurements obtained from our NDB, we will be able to assess the appropriateness of our surgical care, and in the future we will be able to say with confidence that because these guidelines were followed, "The right thing was done right at the right time in the patient’s disease process" [24].

	Government Relations

Top Introduction Introduction Quality and Safety Pay-for-Performance Government Relations Summary Footnotes References

 
Political engagement is not something that physicians gravitate toward naturally. However, the events of the last 15 years have demonstrated that medicine is increasingly dominated by public and private forces beyond the control of physicians. The majority of these external forces focus on the cost of healthcare, and the political solution has been to reduce expenses with ambivalence toward the patient’s best interest. This divergence of priorities eventually results in an ethical dilemma between what is best for the individual versus what is best for society. Almost certainly this dilemma will become center stage in the 21st century [25]. This ethical quandary, however, will neither slow innovation nor reduce the expense it brings.

Then how are we to deal with our centuries old heritage of the best treatment for every patient? We must remain advocates for our patients while at the same time engaging in public dialogue about resource allocation. We must embrace the science of quality and safety that leads to evidence-based surgery and the best practice model of care. We must ensure that the treatment of life-threatening disease remains on the top of our nation’s priority list by demonstrating that new, innovative treatments not only save lives and reduce pain and suffering, but are also cost effective.

But will this be enough? The Balanced Budget Act of 1997 created a sustainable growth rate formula that required actual Medicare physician fees for any given year to equal Medicare target physician fees for the same year. To achieve this neutral balance, an annual Medicare fee schedule update became necessary, and by 2003 this update reached a negative 4.4%. More importantly, the flawed sustainable growth rate formula predicted that physician reimbursement from 2004 through 2012 would decrease each year by 4% to 5%. The consequence of this steep fee reduction was predictable, ie, Medicare reimbursement for physician services would drop sharply below physician expenses, eventually resulting in insufficient resources to meet demand. Ultimately, of course, health care quality for seniors would fall.

The adverse effect of this huge "Medicare cliff" became apparent to Congress, and in March 2003, a statutory update to the sustainable growth rate was provided that resulted in a 1.5% increase in physician fees for the remaining months of 2003. The Medicare Prescription Drug Improvement and Modernization Act of 2003 subsequently provided a similar 1.5% increase for both the 2004 and 2005 fee schedule. The specific 2004 Medicare fees for thoracic surgery were further increased to 4.5% through a 1.5% Medicare increase in reimbursement for professional liability insurance and through the efforts of our Council on Health Policy and Relationships to have CMS accept our practice expense survey data (a 1.5% increase). However, no further adjustments are planned by Congress in the years ahead. Fees in 2005 will remain at the statutory 1.5% increase, but fees from 2006 through 2012 are still projected by the flawed sustainable growth rate formula to decrease each year by 4% to 5%. The consequence of this Medicare cliff will eventually become apparent to society, and ultimately the limits of health care spending will be decided by the public and not by the health care policy makers.

Your Society will continue to be politically engaged. But are we doing enough? Often this past year I have been told that our annual dues are too high and that our Washington, DC effort is ineffective. Let me address both issues. Figure 1 demonstrates that the annual dues for these 10 national surgical organizations range from $200 to $1,270; our dues are $750, close to the middle of this group [26]. Regarding our effectiveness, since 1997 our cumulative expenditures for political engagement have been $8.0 million, including $1.8 million for 2004. During the same time, this investment resulted in a $1.57 billion increase between what Medicare proposed and the actual reimbursement to physicians, a return on investment to our specialty of 19,610%. For what we receive, we should be asking if it is enough. I believe we need to do more.

View larger version (16K): [in this window] [in a new window]   Fig 1. Annual United States surgical dues [26]. (AANS = American Association of Neurological Surgeons; AAO = American Academy of Ophthalmology; AAOS = American Academy of Orthopedic Surgeons; AAOT = American Academy of Otolaryngology; AATS = American Association for Thoracic Surgery; ACOG = American College of Obstetricians and Gynecologists; ACS = American College of Surgeons; ASPS = American Society of Plastic Surgeons; AUA = American Urological Association; STS = The Society of Thoracic Surgeons.)

Thoracic surgeons are not immune to this crisis. On Florida’s east coast, 94% of thoracic surgeons have been sued an average of 3.6 times [27]. Similar high trends occur in other parts of the country. Now it stands to reason that 94% of thoracic surgeons in Florida are not negligent or "bad" doctors. But everyone, physicians and patients alike, suffer from the litigious society we live in, ie, a society with high expectations in which everyone wants a perfect result and in which an understanding of medical reality is low.

Statistics indicate that lawsuits occur frequently. Over 100,000 cases are in our nation’s courts on any given day. Although the end results are on our side, with 70% of lawsuits being dismissed and physicians winning 80% of those that go to trial, the spin-off of this experience invariably affects the practice of medicine. All of us learn to practice "defensive medicine," and a few will move or retire early, neither of which improves the quality of care. Worse yet, the present legal system fails to measure and control negligence. In fact, statistics demonstrate that lawsuits correlate more with patient disability than with physician negligence [27]. The current legal system does, however, decrease access to care, decrease quality, and increase the overall cost of medical care. Physicians are not the only ones concerned. The 2004 National Post-Election Survey demonstrated that by a 22 percentage point margin voters in the last national election believed that the current "medical malpractice system encourages personal injury lawyers to file too many frivolous lawsuits that drive the cost of health care up and drive many good doctors out of business" [29].

What can be done? The time is now for a uniform national approach to resolving this crisis. The 108th Congress failed to enact reforms that stabilize the medical liability system. Although the House of Representatives successfully passed legislative reform to end lawsuit abuse on three separate occasions during the last session, the Senate failed to do so. The provisions of the House of Representatives’ Health Care Act of 2003 (HR 5) and 2004 (HR 4280, HR 4571) are based on the Medical Injury Compensation Reform Act passed in California in 1975. The Health Care Act would provide flexibility across our country by allowing states to individualize caps with respect to state reforms that already exist. This legislation would benefit patients by allowing injured patients to be compensated for all past and future lost wages and medical costs, whereas at the same time limiting the awards for non-economic damages such as pain and suffering to $250,000 [27]. Most importantly, it would provide patients a greater share of the awards by limiting the amount of money that personal injury attorneys receive.

Under Senate Majority Leader William Frist, MD (Republican, TN), Senate Republicans moved to enact similar medical liability reform on four different occasions. The first bill (S 607) never made it to the Committee; the remaining three (S 11, S 2061, and S 2207) were discussed in the Committee, but Democratic Senators led a filibuster on each occasion that blocked the legislation from coming to the floor of the Senate for a vote. A vote to stop the filibuster was taken, but the necessary 60 votes could not be achieved. On each occasion the vote was entirely partisan (49 Republicans, 48 Democrats, and 3 absent; 48 Republicans, 45 Democrats, and 7 absent; 49 Republicans, 48 Democrats, and 3 absent, respectively) [30].

The deadlock in the Senate was the impetus for the formation of the Doctors for Medical Liability Reform (DMLR), a coalition of 10 physician-specialty organizations united to influence the 2004 United States Senate elections. Eight million dollars were raised to fund this campaign, which included $1 million contributed by our Society. This initiative was successful. The DMLR targeted four states (namely, Georgia, North Carolina, South Carolina, and Washington). New Republican Senators were elected in three of these states. The only "DMLR loss" occurred in Washington, but medical liability was fully vented by the media in that state. Equally as important, Senator Maria Cantwell (D, WA) was put on notice that she, too, will face this same issue when she runs for reelection in 2006. Thomas Coburn, MD, a Republican, was also elected to the United States Senate from Oklahoma. Although Oklahoma was not specifically targeted by the DMLR, a number of organizations associated with the DMLR supported his campaign through their separate political action committees (PACs), including our STS-PAC. This was a successful election cycle. The 109th Congress now has 55 Republicans, 44 Democrats, and 1 Independent Senator.

Charles Boustany, Jr, MD, an STS member from Lafayette, Louisiana, was elected to the United States House of Representatives in a December 4, 2004 run-off election for Louisiana’s 7th Congressional District [31]. Dr Boustany is the second thoracic surgeon ever elected to Congress, joining Senate Majority Leader William Frist, MD (R, TN). The STS-PAC contributed the maximum amount possible to his campaign, and our health policy leaders and Washington, DC staff organized the medical community in support of his campaign that resulted in raising tens of thousands of dollars for this effort.

Medical liability reform almost certainly will be on the agenda for the new Congress. But it is not yet law, and we must be prepared to support the next election cycle through our Political Action Committee. Contributions to our STS-PAC for the 2003–2004 United States election cycle (Fig 2) were $339,610 [33]. Although 2004 contributions were nearly double that of 2003, this represented contributions from only 12.3% of our North American members (Fig 3) [33]. Most of our PAC money was spent in the last election cycle. Today, only $62,206 remains. If we are to be successful for the long-term in this medical liability campaign, we need your financial help. The PAC contributions from other organization (Fig 4) ranged from a high of $6,424,156 for the Association of Trial Lawyers of America to a low of $140,969 for the American Society of Cataract & Refractive Surgery [32]. The mean contribution for this group was $1,521,738, more than four times the contribution for thoracic surgeons. We are beginning another election cycle. I urge you to become engaged and contribute to our PAC.

View larger version (14K): [in this window] [in a new window]   Fig 2. Political Action Committee Contributions [32].

View larger version (9K): [in this window] [in a new window]   Fig 3. The Society of Thoracic Surgeons membership, Political Action Committee donors [33].

View larger version (23K): [in this window] [in a new window]   Fig 4. Political Action Committee receipts by organization for 2003–2004 election cycle [32]. (AMA = American Medical Association.)

	Summary

Top Introduction Introduction Quality and Safety Pay-for-Performance Government Relations Summary Footnotes References

As we enter the 21st century, we can look back with pride and gratitude to our predecessors in thoracic surgery who placed a high premium on clinical practice, innovation, and education. It was William J. Mayo, MD, who in 1928 said, "The glory of medicine is that it is constantly moving forward, that there is always more to learn" [34]. We also can look forward to the many challenges that this new century will bring us. My friends, The Society of Thoracic Surgeons is prepared to meet these challenges with you. Through it collectively, and with individual effort by each of us, we can meet these challenges squarely, and we will prevail. Meanwhile, a lot of work still needs to be done.

I’ll see you at the sign-up desk!

	Footnotes

Top Introduction Introduction Quality and Safety Pay-for-Performance Government Relations Summary Footnotes References

 
Presented at the Forty-first Annual Meeting of The Society of Thoracic Surgeons, Tampa, FL, Jan 24–26, 2005.

	References

Top Introduction Introduction Quality and Safety Pay-for-Performance Government Relations Summary Footnotes References

 

1. Kirklin JW, DuShane JW, Patrick RT, et al. Intracardiac surgery with the aid of a mechanical pump-oxygenator system (Gibbon type)report of eight cases. Mayo Clin Proc 1955;30:201-206.[Medline]
2. Institute of Medicine Medicarea strategy for quality assurance. In: Lohr KN, editor. (vol I). Washington DC: National Academy Press; 1990. pp. 21.
3. Institute of Medicine To err is humanbuilding a safer health system. In: Kohn LT, Corrigan JM, Donaldson MS, editors. Washington, DC: National Academy Press; 2000.
4. Agency for Healthcare Research and Quality. Available at http://www.ahrq.gov/about/. Accessed January 4, 2005..
5. National Quality Forum. Available at http://www.qualityforum.org/. Accessed January 4, 2005..
6. The Leapfrog Group. Available at http://www.leapfroggroup.org/. Accessed January 4, 2005..
7. National Quality Forum. Safe practices for better healthcare Available at http://www.qualityforum.org/txsafeexecsumm+order6-8-03public.pdf. Accessed January 4, 2005..
8. National Quality Forum. Serious reportable events in healthcare. Available at http://www.qualityforum.org/neverteaser.pdf. Accessed January 4, 2005..
9. Adverse Health Care Event Statute, Minn. Stat. 144.706-144.7069..
10. Committee on Quality Health Care in America, Institute of Medicine Crossing the quality chasma new health system for the 21st century. Washington, DC: National Academy Press; 2001.
11. Ferguson TB, Coombs LP, Peterson ED. Internal thoracic artery grafting in the elderly patient undergoing coronary artery bypass graftingroom for process improvement?. J Thorac Cardiovasc Surg 2002;123(5):869-880.[Abstract/Free Full Text]
12. Ferguson TB, Coombs LP, Peterson ED. Preoperative ß-blocker use and mortality and morbidity following CABG surgery in North America JAMA 2002;287(17):2221-2227.[Abstract/Free Full Text]
13. Ferguson TB, Peterson ED, Coombs LP, et al. Use of continuous quality improvement to increase use of process measures in patients undergoing coronary artery bypass graft surgerya randomized controlled trial. JAMA 2003;290(1):49-56.[Abstract/Free Full Text]
14. Joint Commission on Accreditation of Healthcare Organizations. Facts about ORYX^® for hospitals. Available at http://www.jcaho.org/accredited+organizations/hospitals/oryx/oryx+facts.htm. Accessed January 4, 2005..
15. American Board of Medical Specialties. Maintenance of certification^© (MOC). Available at http://www.abms.org/moc.asp. Accessed January 4, 2005..
16. Agency for Healthcare Research and Quality. Hospital CAHPS^®. Available at http://www.ahrq.gov/qual/cahps/hcahpfact.htm. Accessed January 4, 2005..
17. Hospital CAHPS^® (HCAHPS^®). Fact sheet, November 5, 2004. Available at http://www.cms.hhs.gov/quality/hospital/. Accessed January 4, 2005..
18. Chen, MY. HealthPartners to withhold payment for errors. Minneapolis StarTribune, October 6, 2004, page 8..
19. Landro L. To get doctors to do better, health plans try cash bonuses. Wall Street Journal, September 17, 2004, page A1..
20. The Hospital Quality Incentive Demonstration Project. Available at http://www.premierinc.com/all/informatics/qualitydemo/overview/index.jsp. Accessed January 4, 2005..
21. Rhode Island Department of Health. Performance Measuring and Reporting. Available at http://www.health.ri.gov/chic/performance/series.php. Accessed January 4, 2005..
22. National Quality Forum. National voluntary consensus standards for cardiac surgery. Available at http://www. qualityforum.org/news/home.htm. Accessed January 4, 2005..
23. Bridges CR, Horvath KA, Nugent WC, et al. The Society of Thoracic Surgeons Practice Guideline Seriestransmyocardial revascularization. Ann Thorac Surg 2004;77:1494-1502.[Abstract/Free Full Text]
24. Edwards FH, Ferguson TB. The Society of Thoracic Surgeons Practice Guidelines Ann Thorac Surg 2004;77:1140-1141.[Free Full Text]
25. Lamm RD. The coming clashpatient advocates vs the public interest. The Pharos 1998;61(4):18-25.
26. Pairolero PC. Personal information, The Society of Thoracic Surgeons Annual Surgical Dues Survey, 2003..
27. Palmisano DJ. The hidden cost of medical liability litigation Ann Thorac Surg 2004;78:9-13.[Free Full Text]
28. American Medical Association. Medical liability reform-now! Available at http://www.ama-assn.org/go/mlrnow. Accessed January 4, 2005..
29. 2004 Post-Election National Survey. Available at http://www.ayresmchenry.com/default.asp?pt=newsdescr&RI=540. Accessed January 4, 2005..
30. U.S. Senate: Legislation & Records. Available at http://www.senate.gov/pagelayout/legislative/g_three_sections_with_teasers/legislative_home.htm. Accessed January 4, 2005..
31. Associated Press. GOP, Democrats trade house seats in Lousiana runoffs. Washington Post, December 5, 2004, page A04..
32. Federal Election Commission, Campaign Finance Reports and Data. Available at http://www.fec.gov/finance/disclosure/srssea.shtml. Accessed January 22, 2005..
33. The Society of Thoracic Surgeons Political Action Committee. December 31, 2004..
34. Mayo WJ. The Aims and Ideals of the American Medical Association J Nat Education A 1928:158-163.

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