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Background: Pay for performance (P4P) models are an emerging way of holding physician payment accountable for quality of care. Current reimbursement methods entail standard payments based solely on procedure performed. As P4P models are instituted, the current payment system does not account for individual patient morbidity and mortality risks.

Hypothesis: A simplistic, validated, peri-operative risk stratification score (Cr-POSSUM) for lower intestinal surgeries can be used as a risk adjustment tool for reimbursement integrating expected outcomes.

Methods: We analyzed single institution retrospective data for four colorectal and three surgical oncology surgeons over a systematic period spanning from 2006-2010 for colorectal cases and captured data for 179 patients. Cr-POSSUM scores were calculated for each patient and t-test analyses were performed using STATA10.

Results: Cr-POSSUM scores for each organ system had broad ranges for small bowel (0.38 - 25.98), colon (0.68 - 57.56), rectal (2.30 - 40.83), and cytoreduction (4.17 - 24.84) surgeries which attest to the vast array of patient mortality despite undergoing similar surgeries. As expected, there was a significant difference in scores among those who had post-operative complications and those who did not (p<0.005). Cytoreductive and rectal surgery had a significant difference in Cr-POSSUM score (p<0.001) when compared to other organ systems. Surgeons whose practice involved a high percentage of cytoreductive and/or rectal surgeries had higher mean Cr-POSSUM scores (p<0.005) and higher complication rates.

Conclusion: When evaluating a surgeon’s performance based on outcomes, the Cr-POSSUM score should be used for risk adjustment in P4P models for lower intestinal surgeries. Current reimbursement systems to not account for individual patient risk.

CRPOSSUM

	n	Mean Cr-POSSUM Score (Range)	P-value	% Post-Op Complications
Organ System
small bowel	29	4.1 (0.4-26.0)	0.09	34%
colon	65	5.6 (0.7-57.6)	0.3	29%
rectal	27	7.9 ( 2.3-40.8)	0.2	40%
cytoreduction	35	9.8 (4.2-24.8)	0.002	37%
Highest Volume Physicians (case volume %)
CRS Doctor 1 (26% rectal)	27	6.6 ( 0.3-40.8)	0.8	56%
CRS Doctor 2 (20% rectal)	53	5.8 (0.3-57.6)	0.5	28%
Surg Onc Doctor 1 (8% rectal)	25	4.8 (0.5-19.6)	0.3	16%
Surg Onc Doctor 2 (94% cytoreduction)	37	9.3 (0.7-24.8)	0.007	39%