"ProvenCareSM": a provider-driven pay-for-performance program for acute episodic cardiac surgical care.
OBJECTIVE
To test whether an integrated delivery system could successfully implement an evidence-based pay-for-performance program for coronary artery bypass graft (CABG) surgery.


METHODS
The program consisted of 3 components: (1) establishing implementable best practices; (2) developing risk-based pricing; (3) establishing a mechanism for patient engagement. Surgeons reviewed all class I and IIa "2004 American Heart Association/American College of Cardiology Guidelines for CABG Surgery" and translated them into 40 verifiable behaviors. These were imbedded within a new ProvenCareSM program and "hardwired" within the electronic health record system, including order sets, templates, and "time outs". Concurrently preoperative, inpatient, and postoperative care within 90 days was packaged into a fixed price. A Patient Compact was developed to highlight the importance of patient activation. All elective CABG patients treated between February 2, 2006 and February 2, 2007 were included (ProvenCareSM Group) and compared with 137 patients treated in 2005 (Conventional Care Group).


RESULTS
Initially, only 59% of patients received all 40 best practice components. At 3 months, program compliance reached 100%, but fell transiently to 86% over the next 3 months. Reliability subsequently increased to 100% and was sustained for the remainder of the study period. The overall trend in reliability was significant at P=0.001. Thirty-day clinical outcomes showed improved trends () but only the likelihood of discharge to home reached statistical significance. Length of stay decreased by 16% and mean hospital charges fell 5.2%.(Table is included in full-text article.)


CONCLUSIONS
A provider-driven pay-for-performance process for CABG, enabled by an electronic health record system, can reliably deliver evidence-based care, fundamentally alter reimbursement incentives, and may ultimately improve outcomes and reduce resource use.
Casale
Alfred S
AS
Richard and Marion Pearsall Heart Hospital, Geisinger Health System, Danville, Wilkes-Barre, Pennsylvania 18711, USA. ascasale@geisinger.edu
Paulus
Ronald A
RA
Selna
Mark J
MJ
Doll
Michael C
MC
Bothe
Albert E
AE
McKinley
Karen E
KE
Berry
Scott A
SA
Davis
Duane E
DE
Gilfillan
Richard J
RJ
Hamory
Bruce H
BH
Steele
Glenn D
GD
D000368:Aged; D001026:Coronary Artery Bypass / Q000191:economics / Q000592:standards; D019033:Delivery of Health Care, Integrated / Q000191:economics / Q000592:standards; D017558:Elective Surgical Procedures / Q000191:economics; D017050:Episode of Care; D019317:Evidence-Based Medicine; D005260:Female; D017722:Hospital Charges; D006760:Hospitalization / Q000191:economics; D006801:Humans; D007902:Length of Stay; D008297:Male; D016347:Medical Records Systems, Computerized; D010351:Patient Discharge; D010358:Patient Participation; D010359:Patient Readmission; D010414:Pennsylvania; D011182:Postoperative Care / Q000191:economics; D011300:Preoperative Care / Q000191:economics; D011445:Prospective Payment System; D012052:Reimbursement, Incentive; D015203:Reproducibility of Results; D018570:Risk Assessment; D016896:Treatment Outcome