Healthcare is increasingly moving toward value-based care and there are several opportunities within the spine arena to create additional value.
Initiatives like bundled payments and accountable care organizations aim to improve quality while reducing overall costs. Here are 15 observations about value-based spine care from experts, including spine surgeons and payer representatives, based on a panel discussion at the North American Spine Society Annual Meeting titled "Implementing Accountable Care in Spine Surgery to Promote Sustainable Health Care."
1. The Centers for Medicare and Medicaid Services initiated a new bundled payment project in 2011 to promote a patient-centered care approach. As a participant in the program, John Bendo, MD, vice chair of clinical affairs at NYU Hospital for Joint Diseases, found it was important to choose high-volume surgeries with predictable outcomes to include in the bundle.
"We had clinical care coordinators follow patients closely throughout their stay," said Dr. Bendo. "That reduced avoidable readmissions or consultant visits."
2. Bundled payments cover the entire care episode from preoperative visits to postoperative hospital stays and rehabilitation center stays. Providers aren't paid extra when patients develop complications or need additional care. "We developed strict preoperative care and post-acute care pathways," said Dr. Bendo. "We followed evidence-based best practices with clinical peer coordinators. They were the quarterbacks of the team and received regular updates on patient progress."
3. Standardization allows physician teams to compare data and control the quality and cost of care. Dr. Bendo and his team completely standardized the inpatient workflow pathways and created a software dashboard with parameters for patient care. Goal-driven rounds were encouraged and patient expectations were enforced for length of stay and postoperative pain management.
4. Keep patients in-house for as much of the care as possible to control the quality and costs. After implementing the CMS bundled payment initiative, Dr. Bendo and his team saw these improvements:
• Average length of stay went from six days to 4.89 days
• Readmission rates went from 20 percent to 14 percent
• Inpatient rehabilitation stays went from 41 percent of patients to 29 percent of patients
5. The surgeons found success with streamlining care, improving quality and meeting cost-reduction goals for spinal fusion. "Ultimately, this will help us adapt to the value-based payments, which will become a standard in the future," said Dr. Bendo.
6. There will be continued effort to innovate in the practice and pricing models in healthcare. "We have to figure out how to bend the cost curve using disruptive technologies," said Sigurd Berven, MD, of UCSF Medical Center. "We have to focus on the cost part of the equation. One of the innovations to focus on is payment reform, because that could be disruptive."
In addition to ACOs and bundled payments, physicians can influence other factors to lower costs and improve outcomes:
• Site of service: outpatient ambulatory surgery centers are often less expensive than inpatient hospital services or hospital outpatient departments.
• Type of surgery: less invasive procedures cut costs in a variety of ways, including quicker rehabilitation, shorter hospital stays and lower infection risk.
• Implants used: Especially for commoditized technology, negotiating with implant companies to lower costs or using wholesale-priced implants makes a big difference.
7. There is a poor correlation between spending and outcomes, says Dr. Berven. "If you spend more, you are less likely to receive good, evidence-based care. Many times patients are seen as a bit of a cash dispenser; we have limited evidence to support standardized protocols, which should be supported. Pay-for-performance may provide a financial incentive for quality of care."
8. Surgeons often don't know the cost of care — whether it's the cost of office visits, hospital stays, implants or economic loss to have the procedure — and therefore don't always make the most cost-effective treatment decisions for patients. "The Scoliosis Research Society has a study showing surgeons have a poor idea of what surgery costs and some knowledge is a prerequisite for us to control costs," said Dr. Berven. "We want to reduce the price and make sure that if we are adding something, we'll get a benefit for that cost."
9. The best way to approach value-based care is to make a short investment that reduces costs over time. "If we just reduce the price 5 percent — it won't be a long term solution," said Dr. Berven. "Sharing responsibility and hopefully being focused on more patient-centered outcomes will help. The hospital then becomes a limited part of the entire continuum. The care goes outpatient or to preventative care and we can improve efficiencies."
10. Self-funded employers are pushing healthcare toward value-based care more than other organizations. Many major Fortune 500 companies have self-funded plans and research providers to make sure their employees seek care at high quality, low cost facilities, even if it means traveling across state lines.
"Employers are looking for new ways to provide healthcare," said Christopher D. Chaput, MD, director of orthopedic research at Scott & White Healthcare in Temple, Texas. "There is rising unpredictability in healthcare costs and unpredictable benefits, particularly for spine surgery. Traditional solutions like patient education and provider networks are aimed at decreasing cost, but don't have the value-based position for the patient that includes vetting the center, concierge travel and quality of care."
11. Employers are looking for centers of excellence for their employees, and developing a medical tourism program can drive additional patient volume and revenue to a spine practice. Dr. Chaput and his team joined the Wal-Mart network where patients have no copays for choosing one of the "preferred" providers for spine surgery, and travel expenses are included. The practice has concierge services with a dedicated registered nurse at the site of service.
12. One of roadblocks for the medical tourism program with Wal-Mart is patient indications. It's difficult to tell whether all patients need surgery before an in-person visit. Dr. Chaput found many patients did not need surgery and were upset when their procedures were denied. There were more than 50 patients screened, but only 13 needed surgery.
"That's not enough to sustain staff additions," said Dr. Chaput. But he was able to offer predictable hospital stay lengths and 67 percent of patients said their surgical outcomes were excellent; 83 percent said they were either good or excellent. "If you introduce these programs and avoid price roll backs, this is a project where everyone could win. Even if it isn't financially profitable, it was a pleasure to take part in the system. Patients were truly cared for and I appreciated that this wasn't a premium service."
13. Payers are increasingly releasing policies driven by "value-based" care practices. The Blue Cross Blue Shield of North Carolina was one of the first; in 2010, the payer released a guideline severely limiting indications for spinal fusions and eliminating spinal fusion coverage for patients with degenerative disc disease beginning in 2011. "We put out criteria based on a rigorous provider review process," said Andrew Bonin, MD, medical director, appeals for BCBS of North Carolina. Providers need coverage assured before undertaking hospitalization and surgery. They fax over the clinical portion of the medical record for indications in the procedure.
14. Current data shows there is extreme variation in how spinal conditions are treated across the country. The Dartmouth Atlas data shows patients with similar indications are more likely to have surgery recommended in some parts of the country than in others. The rate of spinal fusion varies by a factor of more than 14 across hospital referral regions, with the lowest rate being in Bangor, Maine, and highest being in Bradenton, Fla.
This extreme variation, coupled with an increase in spinal fusions in North Carolina and nationally, prompted BCBS of North Carolina to update their coverage policy.
15. Many spine surgeons and professional societies pushed back against the BCBS of North Carolina coverage guidelines. After meetings between both groups, the guidelines were updated to reflect many of the concerns medical professionals had. "We made policy changes after meeting with the spine societies," said Dr. Bonin. However, the payer still doesn't cover spinal fusion for DDD.