Collaborative healthcare and accountable care organizations are on the tips of everyone's tongue today.
Many big hospital and health systems are getting into the game through Medicare ACOs or otherwise, and even private payers are incentivizing these new arrangements for some procedures. The organizations optimize chronic care management and have been successful with routine total joint replacements where the diagnosis, treatment and recovery are fairly predictable; but can a similar model work for the back pain and spine surgery space?
Accountable care organizations — which were developed to meet healthcare reform's goals of high quality, low cost care — encourage efficient and effective treatment for the best value possible. However, reports show Medicare payments for spine surgery vary widely by geography, and even sometimes by hospital, and treatment pathways have similar differentiation. The Dartmouth Atlas report on back pain treatment shows physicians in some regions of the country are more likely to recommend surgery than others on similar patients, and outcomes vary as well.
However, reports also show a huge portion of the cost occurs during the postoperative period, meaning the actual surgery — while costly — pales in comparison to the price paid for long hospital stays, readmissions for complications, reoperations and postoperative nursing and rehabilitation stays.
During a panel session on the issue at the North American Spine Society annual meeting, Andrew Schoenfeld, MD, of the University of Michigan, addressed ways healthcare professionals could address these issues and control costs:
1. Hospitals can decrease the overall cost of care by cutting down on in-directs, staff salary, supply consumption and length of stay.
2. Physicians can change the surgical procedure, implants used and who consults with patients.
3. Postoperative providers can help patients reduce readmissions and resource utilization by optimizing patient education, physical therapy and expectation management.
"If the most expensive hospitals can be moved to the national mean, there would be $162 million in savings," Dr. Schoenfeld said. "There is a capacity to assess the possible winners and losers in the setting of ACOs and bundled payment programs. We can manage the use of discretionary services following discharge. We see that 25 percent of the residual difference in the expense between the spine services is post discharge care. In the ACO setting, there could be a provider or institutional access to narrow networks."
However, Dr. Schoenfeld said the number one things spine surgeons can do to reduce variation and ensure sustainability in spine care is provide better evidence for their treatment going forward. On the other hand, S. Samuel Bederman, MD, of UC Irvine Health, focused on readmissions as the biggest issue for episode of care payments going forward. Most organizations bundle payments for 30 days to 90 days, with rates increasing with the complexity of the surgery.
"We know the risk of complications for some of these complex procedures is high, and reducing them is critical for improving quality and reducing cost," he said. "Improving quality is really the goal. Hospital expenses are outpacing revenue, which could limit access and create disparity for patients who need additional care. They might get inappropriate or no care. It has been estimated that about one-third of healthcare costs could be eliminated without reducing quality."
According to Dr. Bederman, perioperative care is a huge cost. Surgeons see patients, create a surgical plan and obtain clearance for surgery; in that time, patients sees their primary care physician preoperatively and meets with the anesthesiologist for surgical care and the hospitalist for inpatient care, then returns to see an internist after surgery.
"They are handed between providers with redundancies and inefficiency," he said. "The perioperative surgical home really is a new, innovative model for dealing with these inefficiencies. It was developed by the ASA, which put for this patient-centric concept of a physician-led multidisciplinary team of anesthesiologists looking to coordinate perioperative care. It's a continuum of care instead of the patient being handed off from provider to provider; they just have one person they're working with."
The perioperative surgical home's goal is to reduce waste in healthcare spending and complications, which then reduce costs. Similar tactics have been developed in other industries, such as the Lean program or Six Sigma, and healthcare is now catching up.
"This current trend is unsustainable and we need to improve the perioperative care and surgical technologies," Dr. Bederman said.
Stephen Bartol, MD, of Henry Ford Health System, agreed, stating that pay-for-performance is coming "whether we like it or not."
"The findings suggest pay-for-performance can be cost-effective, but the evidence is not convincing," he said. There are still several questions when deciding what constitutes "good" performance and bonus payments. Key questions include:
1. How large should the rewards be?
2. Should the program use withholds or bonuses?
3. How should rewards be distributed?
4. Should there be tiered for absolute targets?
5. Should the payments be coupled or decoupled?
"For surgeons, the biggest questions center around the biggest targets," said Dr. Bartol. "What are you paying me to do? Picking a target isn't easy. For chronic diseases, that's pretty easy. Family doctors can manage blood pressure or diabetes. It's easy to set targets there, but surgeons are managing complex problems. How do you fit them into a target? The measures currently in place don't impact the things we actually do."
Surgeons want to know whether they are using the correct judgment for patient selection, performing the right procedure and employing good technical skill. These qualities are difficult to measure quantitatively and as a result payers are using surrogate targets like adhering to antibiotic guidelines and anticoagulation prophylaxis.
"The measures in place today are not fair," said Dr. Bartol. "Pay for performance is focusing on easy-to-obtain metrics and not the things that matter to us, and that's a problem."
Dr. Bartol and his team are part of the Michigan Spine Surgery Improvement Collaborative, launched in September 2013, as a partnership between Michigan providers, Blue Cross Blue Shield of Michigan and Blue Care Network to gather data that will help improve outcomes for spine surgery patients. Surgeons own their data within the collaborative. Their targets evolve over time to reflect value as determined by surgeons.
Nationally, surgeons and care providers are looking for ways to continuously improve on quality using feedback from systematically collected data. They are providing feedback to their teams at regular meetings and making rapid changes based on the data. It is important that continuous quality improvement efforts have these characteristics:
1. Non-punitive, confidential reporting
2. Identifies errors, including near misses
3. Allows providers to correct and prevent issues
"The reality is [pay-for-performance] is coming, the landscape is changing; pay-for-performance is real," said Dr. Bartol. "Organize someone in the practice to spearhead the effort and enlist hospitals. Help them and expect help from them. Incorporate all the low-hanging fruit. Learn about PQRS, start tracking what is actually meaningful and important to you. Let payers know you are the expert and share what you are doing to improve quality. At the end of the day, you need to own your data and take charge."