Two orthopedic surgeons weigh in on payer obstacles they expect to see in 2022, from reimbursement issues to payer investment in health programs.
Ask Orthopedic Surgeons is a weekly series of questions posed to surgeons around the country about clinical, business and policy issues affecting orthopedic care. We invite all orthopedic surgeon and specialist responses.
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Note: Responses were edited for style.
Question: What's the biggest payer obstacle you anticipate in 2022?
David Jacofsky, MD. The CORE Institute (Phoenix): The biggest payer obstacle in 2022 is likely going to be similar to what it has been over the past few years. Namely, the disconnect between risk-based programs that payers are asking organizations to embrace and their ability to execute on those same programs.
Most payers claim to be anxious to move into value-based arrangements in the musculoskeletal space given unsustainable trends in cost, but oftentimes they ultimately lack the data systems and infrastructure to manage, attribute and/or price such programs. Outsourcing data management for value-based programs by payers leads to a cookie cutter formulaic approach to how performance is measured that typically causes erosion of the ability to measure what really matters in driving value. These formulaic approaches typically lead to problems with attribution and due to this, in many cases, can actually incentivize physicians in ways that save money on episodes of care or chronic-condition-based bundles but sometimes actually increase the total cost of care.
Payers seem hesitant to meaningfully invest in real population health pilot programs in orthopedics on a broad basis, and many markets are complicated by risk being previously capitated to accountable care organizations and primary care physician groups who historically can’t manage subspecialty surgical risk well but may be handcuffed in their ability to easily partner with orthopedic groups due to contractual, claims adjudication or data availability issues. All of this means that orthopedic groups must either partner with experienced organizations or significantly invest internally over time to develop infrastructure, meaningful and validated benchmarks and metrics, claims systems and actuarial medical economics capabilities so that they can approach payers with data, pricing, and a program proposal that will meaningfully bend the cost curve in musculoskeletal care while also being easily understandable and adoptable by payers and providers.
Jason Snibbe, MD. Snibbe Orthopedics (Los Angeles): The biggest payer obstacle is the continued reduction in reimbursement. There have been multiple articles published over the last two years indicating that current reimbursement is not sustainable. The increased costs of employees, insurance and rent does not match the pay that insurance companies pay. They continue to reduce reimbursement. Physicians and surgeons will continue to be forced to leave insurance plans and charge more for surgeries. It has become unsustainable.