New Medicare chief trades scalpel for bureaucrat's pen.

Dr. Jeffrey Rich is trading in his scalpel for a bureaucrat's pen in the hope that he'll give Medicare a strong and credible push into a future that will reward those who deliver high-quality care at the best cost. The cardiothoracic surgeon took over as director of the Center for Medicare Management in February.

Dr. Rich, who serves on the board of directors for the Society of Thoracic Surgeons, has delved deeply into restructuring reimbursement to reward quality care through his work with the National Quality Forum, the Hospital Quality Alliance, the Surgical Quality Alliance, and the AQA alliance, among other organizations.

He also helped launch the Virginia Cardiac Surgery Quality Initiative, which was one of the initial participants in CMS's Hospital Quality Incentive Demonstration project. Dr. Rich is currently chairman of the board of directors for the Virginia initiative and is also a member of the quality committee. On three occasions, Dr. Rich has testified before Congress on how the federal government could construct a payment system to reward quality. He also gave a congressional briefing on pay for performance.

Even so, he's often felt like an outsider, trying to get policy makers' attention. Now, he'll be on the inside. "I get a chance to open a door instead of knocking on it," Dr. Rich said in an interview, noting that he's been "knocking on doors for years."

As director of the Center for Medicare Management, he will lead several federal initiatives, such as instituting competitive bidding for durable medical equipment, implementing the Medicare Administrative Contractor program, and overseeing the development and promulgation of rules pertaining to inpatient, outpatient, and physician payments.

But his top priority is guiding the center's value-based purchasing initiative. The Virginia Cardiac Surgery Quality Initiative ably combined the CMS administrative claims database with the Society of Thoracic Surgery registry, said Dr. Rich, adding that he'd like to do something similar while at CMS.

"My hope is that we do create a value-based purchasing system with credible data and that will engender trust with providers," he said. The key will be to use "market-based approaches, not mandates."

Although he's excited about his opportunities with CMS, Dr. Rich has some sadness about his forced retirement from surgery. "It didn't feel good to resign from my practice," he said. Dr. Rich was a surgeon with a group cardiothoracic surgery practice based at Sentara Heart Hospital in Norfolk, Va.

Government ethics rules dictated that he quit, said Dr. Rich, although he added that he will be able to keep his hand in surgery by occasionally taking call when he returns home to Norfolk on the weekends after a work week split between Washington and CMS's Baltimore headquarters. That light duty has been cleared by the feds.

And, most likely, he'll be back to the operating room early next year. As with all presidential appointees, the law requires that he resign his position by the time the next president is sworn in on Jan. 20, 2009.

Although he could be kept on, Dr. Rich said "I'm not anticipating being there more than a year."