Pay-for-performance project to improve cardiovascular care

Thousands of heart patients in the Greater New York region will receive top quality, comprehensive cardiac care in an innovative cardiovascular program in which physicians at a major academic medical center will receive incentive payments based on 60 performance measures for outpatient and inpatient care.

The program is one of many pioneering initiatives at Montefiore Medical Center's nationally recognized Montefiore-Einstein Heart Center and will challenge physicians to score well on a mix of measurable activities that indicate quality care for patients, such as: is the patient enrolled in a smoking cessation program; has beta blocker therapy been persistent; is blood pressure under control; and, was the patient generally satisfied with his care? The program is for heart patients and for patients with risk factors for heart disease, such as diabetes, hypertension, hypercholesterolemia, smoking and obesity.

Montefiore is the only hospital in New York State to initiate such a pay- for-performance program, which is being funded by a $2.4 million grant from the New York State Health Department.

"Cardiovascular care has advanced considerably over the past decades through prevention programs, clinical drug trials and advancements in surgery such as robotics," said Steven M. Safyer, MD, Senior Vice President and Chief Medical Officer, Montefiore. "This state grant supports Montefiore's continuing focus on innovations in cardiovascular treatment by adding a new approach. It gives us the opportunity to look at the physician side of the equation and to implement a model pay-for-performance cardiac care program."

Here's how the pay-for-performance project will work in an outpatient setting for one group of patients -- those who are at-risk for heart disease. If a physician in one of Montefiore's ambulatory care centers meets certain clinical performance standards for her patients (such as controlling high blood pressure, checking weight, providing nutrition counseling, checking smoking status, and giving a flu vaccine), she could earn an income bonus. The higher her score is on the list of performance standards that are recorded electronically, the larger the bonus -- up to a certain maximum. The same type of financial incentives, with different performance criteria, would apply to treating patients with existing heart disease or diabetes.

"This approach aligns the incentives for patient, physician and hospital in order to promote best practices and optimal outcomes," said Safyer.

Montefiore will use its unique clinical information system to quantify performance.

In the more complex environment of an inpatient hospital setting, performance measurements will go beyond clinical data to include the number of readmissions for heart care patients within a year's time and patient satisfaction survey scores.

"This project breaks new ground," said Rohit Bhalla, MD, Chief Quality Officer at Montefiore. "Most pay-for-performance experiments are conducted by insurers, not providers. Providers generally do not have an incentive to reduce utilization."

"Montefiore is uniquely positioned for this grant," said Stephen Rosenthal, president of Montefiore's CMO, the Care Management Company. "We have a pioneering care coordinating program (Care Guidancesm) for 150,000 Bronx patients for whom we are not only the provider, but also act as an insurer. Therefore, we have an alignment of all the right incentives to improve quality and optimize appropriate utilization for these patients. Most hospitals have not adopted at-risk arrangements such as this, which has very similar incentives to the pay-for-performance model."

Unique aspects of the Montefiore pay-for-performance grant: -- It is highly unusual for a hospital to be in such a program. -- Montefiore is partnering with the state and insurers to create an incentive pool of monies. -- Montefiore can measure performance standards across an integrated system of care -- in an inpatient hospital setting and throughout its many medical group outpatient settings. -- It is "payer neutral" because the physician will see only one set of criteria for incentive pay. Currently, each insurer has its own separate set of performance standards, which is confusing for the physician. -- Pay-for-performance measurements will extend beyond just clinical standards, and include patient satisfaction surveys and utilization rates. -- Montefiore is using a highly sophisticated, existing clinical information system to measure both the performance standards required by the state and an additional dozen standards of care added by Montefiore.

Montefiore Medical Center, The University Hospital and Academic Medical Center for the Albert Einstein College of Medicine, encompasses 125 years of innovative medical "firsts," pioneering clinical research, dedicated community service and ground-breaking social activism.

A full-service, integrated delivery system caring for patients from New York, Westchester County and beyond, Montefiore is a 1,122-bed medical center that includes three hospitals: the Henry and Lucy Moses Division, the Jack D. Weiler Hospital and The Children's Hospital at Montefiore; a large home healthcare agency; the first and largest school health program in the U.S.; a 21-site medical group practice integrated throughout the Bronx and Westchester; and a care management organization providing services to 179,000 health plan members.

The medical center is ranked by the prestigious Leapfrog Group among the top one percent of all U.S. hospitals based on its strategic investments in sophisticated and integrated healthcare technology.

Montefiore's distinguished centers of excellence include cardiology and cardiac surgery, cancer care, tissue and organ transplantation, children's health, women's health, obesity, diabetes, surgery and the surgical subspecialties. Montefiore is a leader in the treatment of headaches, cough and sleep disorders, geriatrics and geriatric psychiatry, neurology and neurosurgery, bioethics, adolescent and family medicine, HIV/AIDS and social medicine, among many other specialties.