Healthcare is moving head-first toward shared-risk and shared-savings care delivery models. The most progressive organizations are testing accountable care organizations, bundled payments and narrow networks to reduce waste and improve outcomes. But can they work?
Shared savings is a slippery slope for specialty care, including spine surgery for several reasons:
• There are gaps in the literature to prove definitively which treatments work.
• Back pain patients are different and taking the "one-size-fits-all" approach to treating most diagnoses has widely varying outcomes.
• Without meaningful tort reform, surgeons are still responsible for ordering certain tests — even wasteful tests — to cover their bases.
• Patient lifestyle and attitudes have a huge impact on spine surgery outcomes.
• Spine care and surgery is expensive, impacting patients with high deductibles.
While ACO and other shared savings program structures vary, the basic tenets are the same: bring together healthcare providers and patients to take on more responsibility for the outcomes and payment in an effort to improve quality and lower costs. In many cases, payers pay a lump sum for care and won't cover treatment for preventable complications, infections or revision surgeries related to the initial treatment. So providers are responsible for good outcomes, otherwise they're required to foot the bill for additional treatment.
As a result, providers participating in shared savings select patients who have fairly predictable outcomes to include in the ACO while more complex patients are covered in a more traditional payer model.
Patients often have less stake — although their portion of the bill is steadily rising. This could have the reverse impact on quality care; if patients have to pay more, they may decline necessary care as well. "Increasing patient cost sharing is a blunt instrument: research shows that it can reduce use of both low- and high-value care, which suggests that patients do not have the information or skill required to differentiate between the two," according to an article published in the New England Journal of Medicine by Carrie H. Colla, PhD. "Patient cost sharing in commercial insurance has been increasing, but it can diminish use of low-value care in a targeted way only if patients are given enough support to make good decisions."
Many patients don't understand their part in improving outcomes, and even those who receive education on changing their lifestyle find total transformation difficult. Habits like smoking, opioid use, overeating, under-exercising and chronic depression lead to worse spine surgery outcomes. How responsible are surgeons for these patients?
Defensive medicine is another concern. A national survey quoted in the NEJM article shows 92 percent of physicians feel responsible for making sure patients avoid unnecessary tests, but according to an AAOS article 92 percent of surgeons also report ordering unnecessary tests to protect themselves. Most states have not enacted meaningful tort reform, leaving surgeons with few options for eliminating some low-value care.
There are some efforts to improve data collection and accessibility as well as patient education on spine care. National and local registries are now gathering a high volume of information on spine patient outcomes and can generate granular reports to help surgeons factor in as many unique characteristics about the patient as possible to direct the patient toward the best care for them. But more data is needed to make effective changes.
"Theory suggests that we can have strong, targeted, service-level financial incentives only in cases in which we have precise, up-to-date measurement. Measurement of low-value care is not yet robust enough to inform service-level interventions," according Dr. Colla in the NEJM article. Spine care is making headway, but there is a long ways to go.
Additional patient education tools such as Consumer Reports and the Choosing Wisely campaign (embraced by the North American Spine Society, American Association for Neurological Surgeons and American Academy of Orthopaedic surgeons) have released patient and physician education materials about eliminating low-value care, but that's just the start.
"Most evidence regarding consumer-education campaigns also comes from research on under-use, and findings suggest that such efforts are weak instruments for changing patient behavior," according to Dr. Colla. These education tools also aren't always nuanced for patients with various comorbidities and could be confusing, especially if patients are finding the tools online by themselves.
So how can surgeons meaningfully reduce low-value spine care? The NEJM article suggests:
• Label low-value care
• Strengthening risk-adjusted outcome measurement
• Developing new practice-based measures to reduce low-volume care
• Increase financial support to develop and disseminate strategies
• Invest in patient decision aids, clinical decision support and clinician education and feedback
Effectively addressing these issues could help payers and regulators recognize the long-term value of care and insight policy changes in the future. "Current performance in delivering effective services reflects decades of progress made through quality-improvement efforts aligned with incentive inherent in fee-for-service and reimbursement. To address overuse, we now need to work against the current of culture and payment models that still largely reward volume over value," said Dr. Colla in the NEJM article.