How are physicians — especially specialists — interacting with population health?
It's moving physicians from the fee-for-service model where "more is better" to the risk-based model where "less is more." But physicians are still accountable for providing good quality care and outcomes in addition to lowering costs. So where are the biggest opportunities to reach these goals?
• Eliminating waste
• Reducing medical errors
• Eliminating unnecessary testing
• Preventing 30-day readmissions
"We are a healthcare system on the edge of a big decision. Are we really able to make the change from volume to value?" asked David B. Nash, MD, MBA, Founding Dean of the Jefferson School of Population Health at the 13the Annual Spine, Orthopedic & Pain Management-Driven ASC Conference + The Future of Spine. Patients come in all shapes and sizes, and a variety of factors impact their health, from their socioeconomic status to socialization. The biggest predictor of a person's health isn't what you think.
"The most important five-digit number I need to know about you to predict your life span is your zip code," says Dr. Nash. Bedside medical care is only about 10 percent to 20 percent of what makes a society overall healthy considering population health.
"From a society perspective, the access to good medical care is only a small part of the story," says Dr. Nash. "Twenty percent is mom and dad; 20 percent is where you live; 50 percent is individual behavior. But if you look at how we spend our money, most of it is on medical services. We spend so much on a small percentage of what actually contributes to make us healthy. That's the conundrum. That's the inner guts. That's what the complexity of population health is all about."
Healthcare delivery changes
Healthcare delivery is changing, and the most successful providers in the future are already beginning to reshape care delivery around care coordination. These providers are connecting patients with rehabilitation, occupational therapy, behavior modification and pain control in addition to their specialists. The information about each patient circulates among all their care providers.
"That is what population health, in a very practical way, is going to be all about," says Dr. Nash. "Even five years ago, none of this existed. As we move from volume to value, the challenges are incredible."
There are physicians doing things like pre-habilitation to engage core strength activity and physical therapy before surgery to prepare for better outcomes. Exercising can also help the patient lose some weight before surgery, which is associated with better outcomes as well. Practices are also hiring nutritionists, exercise physiologists and diabetes nurse practitioners to help patients live more healthy lives. Others are working with home health providers to ensure patients have a consistent care plan when they return home from surgery.
"At the moment, we don't get paid to improve behavior, but we will be paid to improve behavior in the world that's moving from volume to value," says Dr. Nash.
Payment models
The move toward population health, coordinated care and risk-based payment models will have an impact on specialists in the future. Primary care physicians are already going at-risk for their patient outcomes at a higher rate than ever before, and they share payments with their specialists.
"If primary care physicians are sharing their money with a spine surgeon, he's pick the high volume spine surgeon who has good outcomes and not a lot of waste," says Dr. Nash. The primary care physicians will look for surgeons who can control pain well and have high patient satisfaction, because the patient's surgical experience will impact the final payment overall. There will be transparency in outcomes not only between the physicians, but also with payers and hospitals. Ultimately, much of this data will be published online and other media outlets.
"If you're going to be naked, you better be buff," says Dr. Nash. "If there's no outcome, there's no income; no measurable, good coordinated care, reduced readmissions, no payment or low payment."
Dr. Nash suggests spine surgeons focus on these areas to prepare for population health:
1. Practice based on the best available evidence
2. Reduce unexplained clinical variation among specialists in the practice
3. Reduce slavish adherence to professional autonomy
4. Continuously measure and close the feedback loop.
5. Engage patients across the continuum.
5 predictions for spine surgeons
As for spine care, Dr. Nash has a few predictions for where spine practices will trend in the future:
1. The number of spinal fusion procedures will increase significantly with the aging baby boomer population.
2. Ambulatory surgery centers will be a huge opportunity in the future because surgeons can provide quality care at a lower cost, and mobilize patients more quickly.
3. Readmission rates are still higher than most facilities desire for spinal fusions, and many times patients are returning to emergency rooms at other hospitals than the one where their original surgery was performed. This will create problems in the future.
4. The average age of the spine surgery patient will creep into the 60s as people live longer and desire to remain active longer.
5. High-volume surgeons will be more sought after, until spine-focused surgeons are performing the vast majority of cases. Low volume surgeons often have worse outcomes, longer length of stay and high complication rates than high volume surgeons, according to the literature.