benign hysterectomy in the macra era - wesley ob/gyn · 2017-12-20 · benign hysterectomy...
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Benign Hysterectomy in the MACRA Era
Simon Patton, MD
Fellow, FPMRS
Gary Larson, Far Side
Learning objectives
• Explain the background and basic purpose
of the MACRA law
• Discuss healthcare quality as it pertains to
benign hysterectomy
• Examine nationwide trends affecting
hysterectomy
Disclosures• No financial disclosures
Learning objectives
• Explain the background and basic purpose
of the MACRA law
• Discuss healthcare quality as it pertains to
benign hysterectomy
• Examine nationwide trends affecting
hysterectomy
BACKGROUND
• Medicare SGR
• Part of Balanced Budget Act of 1997
• Every year face the “doc fix”
• By 2015 appropriate adjustment would
have been 21%
3 Problems
Cost OutcomesSGR
“Doc Fix”
MACRAMedicare and CHIP Reauthorization ACT
H.R. 2—114th Congress
Signed into law April 16, 2015
1. Repeals Sustainable Growth Rate (SGR)
2. Streamlines quality reporting measures
3. Links Medicare Payments to Quality
**NOT Affordable Care Act
MACRA
Rep Michael BurgessTX 26th district
MACRA
Rep Michael BurgessTX 26th district
AMA Guide to Physician Focused Alternative Payment Models
AMA Guide to Physician Focused Alternative Payment Models
MIPSMerit-Based Incentive Payment System
Old measure MIPS 2019
PQRS Quality 50%
Meaningful use Advancing Care Information 25%
Value based modifier Resource use 10%
[New] Improvement activities 15%
qpp.cms.gov
qpp.cms.gov
Quality
• 271 different quality measures
• “high priority” outcome measure and “cross
cutting”
• Exampleso Appropriate work up prior to endometrial ablation
o Breast cancer screening
o Cervical cancer screening
o Chlamydia screening and follow up
o Maternal depression screening
o Osteoporosis management in women who had a fracture
qpp.cms.gov
Resource Use• Replaces the value based modifier
• CMS will calculate this metric based on claims data
to calculate medicare spending per benificiary
• No discreet reporting required by clinician
qpp.cms.gov
Advancing care information
• 15 measures
• Examples:o Clinical registry participation
o e-prescribing
o patient-specific education
o secure messaging
o summary of care
qpp.cms.gov
Improvement Activities• 92 measures to choose from
• choose 4 improvement activities for a minimum of
90 days
• Examples:o Regular training in care coordination
o Use tools to help patient with self-management
o use of patient safety tools
o provide pre-visit development of a shared visit agenda with patient
o improvements that lead to more timely communication of test results
qpp.cms.gov
Alternative Payment Models
• Payment models that reward
physicians for high quality and
cost efficient care
AMA Guide to Physician Focused Alternative Payment Models
QUALITY
APM Examples
• COPD and Asthma Monitoring Project
(CAMP)
• Hospital at Home (HaH)
Learning objectives
• Explain the background and basic purpose
of the MACRA law
• Discuss quality as it pertains to benign
hysterectomy
• Examine nationwide trends affecting
hysterectomy
“If we don’t’ figure out what a quality hysterectomy looks
like, then payers will figure out what those metrics look like
for us”
ACOG.org
Benign Hysterectomy APM
Defining episode Patient reported outcomes
• Trigger / Duration
• Relevant diagnoses
• Relevant services
• Sequelae
• Pain
• Regret
• Sexual function
• Fatigue
• Satisfaction
Quality measures
Oophorectomy in patients <65 without family
history of cancer
Treatment of AUB-L
ER visits, hospital re-admission, outpatient
visits
Quality and Surgical Volume
• Mehta et al, AJOG 2017
o 5660 Hysterectomies performed by general
OBGYN in Maryland
o 68% surgeons performed <10/year (45%
performed <5)
o Adjusted OR 1.73 for postoperative
complications for very low volume surgeons
Quality and Surgical Volume
• Mowat et al, AJOG 2016
o Meta analysis 741,760 patients
o Adjusted OR 2.8 for total complications in low
volume surgeons
• OR 1.7 ureteric injury
• OR 2.2 vascular injury
• 17 min operating time
• 60cc blood loss
Surgeon volume and outcomes
• Vree et al, JSLS 2014
o 1914 hysterectomies at a tertiary care facility
o Operative time 217 vs 166 min
o EBL 152 vs 92 cc
• Rogo Gupta et al, Obstet Gynecol 2010
o Examine surgical volume and resource use in vaginal hysterectomy
o High volume surgeon (>13/year) 31% less likely to sustain operative injury
o High volume surgeon $609 less for vaginal hysterectomy
Vree et al, JSLS 2014
Learning objectives
• Explain the background and basic purpose
of the MACRA law
• Discuss healthcare quality as it pertains to
benign hysterectomy
• Examine nationwide trends affecting
hysterectomy
“To meet obstetrical demand, there are too many trainees relative to surgical volume; thus obstetrics and gynecology has the highest number of surgeons per capita of any specialty5.”
647
129
“To meet obstetrical demand, there are too many trainees relative to surgical volume; thus obstetrics and gynecology has the highest number of surgeons per capita of any specialty5.”
Clinical volume
• OBGYNo 2.65 OB-GYN per 10,000 women
o 13.25 per 100,000 population
• Rayburn et al, Obstet Gynecol 2012
• GENERAL SURGERYo 5.8 per 100,00**
• **internet
41,481
AAMC Physician Specialty Book 2016
25,254
41,481
AAMC Physician Specialty Book 2016
41,481
25,254
164%
AAMC Physician Specialty Book 2016
41,481
25,254
323%
AAMC Physician Specialty Book 2016
0
200
400
600
800
1000
1200
1400
1600
OBGYN GeneralSurgery
Top 3 Case Types, in Thousands
859,000
1,369,000
Wier et al HCUP Statistical brief #188, 2015
0
200
400
600
800
1000
1200
1400
1600
OBGYN GeneralSurgery
Top 3 Case Types, in Thousands
67%859,000
1,369,000
Wier et al HCUP Statistical brief #188, 2015
Hysterectomy trends• Wright et al, 2013
o Significant decrease in number of inpatient hysterectomies
from 1998 to 2010
o 681,234 in 2002 433,621 in 2010
o By indication
• Leiomyoma
• Abnormal uterine bleeding
• Benign ovarian neoplasm
• Endometriosis
• Pelvic organ prolapse
• Gynecologic cancer
Inpatient Hysterectomies 1998-2010
Wright et al, AJOG 2013
Resident Experience
Washburn et al, JMIG 2014
TVH LAVH
TLH RA-TLH
Minimum cases for proficiency
• TVH o 21-27 cases to be considered “minimally competent”
• Jelovsek J et al, Am J Obstet Gynecol 2010
• TLH o 30 cases to complete learning curve
• Twijnstra et al, Obstet Gynecol 2012
• RA TLH o 91 Cases for “surgical proficiency”
• Woelk et al, Obstet Gynecol 2013
After residency?
• 80% could not independently perform a vaginal
hysterectomyo Guntapalli et al, Obstet Gynecol 2015
• 49% could not independently perform a
hysterectomyo Doo et al, Gynecol Oncol Rep 2015
.
After residency?
• 42% Felt “very confident” in performing TLH/LAVHo Chen et al, Obstet Gyenecol 2016
• 27.8% “completely prepared” to perform TVHo Burkett et al, FPRMS 2011
Cundiff, OBGYN MGMT 2017
THANK YOU
OBGYN
Case type Number in thousands
Other excision of uterus and cervix 234
Other OR therapeutic procedures; female organs
233
Hysterectomy 392
Total 859
General Surgery
Case type Number in thousands
Cholecystectomy/common bile duct exploration
683
Inguinal and femoral hernia repair 288
Other hernia repair 398
Total 1,369
=62.7%
Value
Quality
Costs
=
Value
Quality
Costs
=
Duty hours?
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