In April, Pacific Business Group on Health expanded its Employers Centers of Excellence Network to include spine surgery. The network covers employees from large companies, including Walmart and Lowe's, sending patients to a regional "center of excellence" for certain procedures. The network initially provided hip and knee replacements to employees last year for a bundled rate and their expansion into spine heralds trends for the future.
"I believe we will continue to see increasing efforts on the part of employers and large corporations to be direct purchasers of healthcare services," says Jonathan Slotkin, MD, director of spinal surgery, Geisinger Health System Neuroscience Institute. "Programs of this type feature bundled rates, transparency and vigorous iterative assessment of quality outcomes and patient satisfaction." Dr. Slotkin is also the medical director of Geisinger in Motion, Division of Applied Research and Clinical Informatics, Geisinger Health System.
The patients participating in the program don't have travel expenses or copayments for their services within the program. "These employers have been on the leading edge of value-centered care delivery, and we can expect more employers and corporations to engage in direct purchasing of healthcare for their associates," says Dr. Slotkin. "It is worthwhile for providers to assess their readiness for participation and leadership in these types of programs."
The Centers for Medicare and Medicaid Services is also moving more toward bundled payment programs. Their bundled payment program that was initially voluntary for total joint replacements could become mandatory in the near future. In July, CMS proposed requiring hospitals to participate in the five-year Comprehensive Care for Joint Replacement payment model holding hospitals accountable for quality and costs of care from the time of surgery through 90 days after discharge.
"The shift from payers assuming financial and insurance risk to providers and systems assuming financial and insurance risk is moving along inexorably at this point," says Dr. Slotkin. "We are continuing along the risk continuum towards true population health management. Picture a scenario where a payer gives a delivery system, let's say $8,000 per covered life for a year's worth of care. We have seen CMS engage in pilot programs like this already for 35,000 or more covered lives at a time."
The shift toward bundled payments is driving spine surgeons to focus more on cost and quality as part of the value equation. Surgeons in private practice as well as the academic setting are becoming more disciplined in their efforts to measure outcomes, and more tools are available to gather data. In addition to electronic medical records and data gathering software at the hospital, the prospective registries like the American Association of Neurological Surgeons' National Neurosurgery Quality and Outcomes Database are open.
"There is solid participation in N2QOD from a range of smaller private groups, group practices and large academic enterprises," says Dr. Slotkin. "There also continue to be great surgeons who apart from participating in the databases work to rigorously measure the effect of the care they provide in their own practices."
There are several challenges associated with measuring the true cost of care for spine conditions. The traditional measurement of cost has been focused on collections, tracking charges and collections and then measuring the shortfall between them. Most also have a handle on item expenses, payroll and direct costs of human capital. But it takes more work to paint the true cost picture.
"In an era where we and the larger delivery enterprises we interact with are faced with population health management, our comfortable methods of understanding cost and revenue are significantly inadequate," says Dr. Slotkin. "We need to strive to measure and understand the true cost of care delivery around entire cycles of care. Methods of costing that embrace outcomes and account for provider time investment are needed. Techniques of this type that account well for provider non-clinical time investment and individual human capacity cost include, for example, Time-Driven Activity-Based Costing."
Robert Kaplan and Michael Porter authored the Harvard Business Review article "The Big Idea: How to solve the cost crisis in health care" describing the time-driven activity-based costing. Mr. Kaplan and Derek Haas also authored the article "How not to cut health care costs" offering a starting point for surgeons who want to know more about new methods for cost analysis in the value care era.
Embracing value care delivery is important for both operational effectiveness and strategic positioning within care delivery systems. The value equation means providing superior outcomes and quality with significantly improved cost efficiency as compared to how surgeons have previously provided care.
Payment systems based on quality include both outcomes and patient satisfaction. Measuring patient satisfaction is difficult. "Published work in the general medical literature has shown that in certain patient populations there can in some instances in fact be an inverse correlation between patient satisfaction and quality outcomes," says Dr. Slotkin. "But yet quality and patient satisfaction will both continue to be goals we must aim to achieve."
Everyone from legislators to payers, consumers, regulators, startup and mature companies, and corporate purchasers of healthcare have become part of the "quality industrial apparatus" of healthcare. These stakeholders are ready to advance their agendas, and the system will move forward with or without surgical representation.
"We as surgeons must continue to embrace and master value care delivery, policy and the finance ramifications of this care model," says Dr. Slotkin. "We should, as a continuous goal, seek leadership roles in local and national discussion of such programs with an unwavering advocacy for the patients that we care for and the specialty expertise we possess."
Healthcare across the board is shifting to population health management and clear data shows the value of spinal surgeons' expertise.
"This shift to population health management underscores why being solid technical surgeons and even striving to measure our individual clinical outcomes are now not enough," says Dr. Slotkin. Surgeons are now functioning in a larger context where a myriad of other health management concerns have impact across the continuum of care delivery:
● ER readmissions
● Narcotic utilization
● Patient return to work
● Continued patient utilization of related services such as interventional pain management and physical therapy services
"When we view our spinal surgical patients in the context of the full cycle of chronic care delivery for their disease process and its related conditions, we begin to take ownership for our part of population health management," says Dr. Slotkin.
Over the next five years there is great room for innovation in patient engagement and patient experience. Currently, patient engagement is important but at times somewhat nebulous and difficult for providers to grasp.
"I think we need to begin to approach patient experience with the same discipline that we currently apply to quality initiatives," says Dr. Slotkin. "We have started work in earnest on reengineering delivery systems and workflows surrounding patient experience. We are applying many of the same principles we have grown accustomed to in the quality arena: hardwiring, effect analysis, consensus building and failure mode redesign. As we begin to approach patient experience with the same reproducible rigor that we have historically applied to quality improvement work, we will see this space start to much more resemble a hard science."