Published 8/1/2013
Julie Balch Samora, MD, PhD, MPH; David B. Bumpass, MD

Gaining an Edge in the Coming Quality Revolution

A report from the AAOS “Shifting from Volume to Value” course

Julie Balch Samora, MD, PhD, MPH, and David B. Bumpass, MD

As implementation of the Affordable Care Act rolls forward, physicians face the challenges of new payment models and the introduction of quality metrics as part of insurance reimbursements. To help members meet these challenges, the AAOS recently sponsored a 2-day forum, “Shifting from Volume to Value: Preparing Your Practice for Health Reform.”

The program, led by course directors Kevin J. Bozic, MD, MBA, and Anthony M. DiGioia III, MD, focused on the increasing importance of value in health care and was designed to help providers create strategies to increase the value of care they deliver to patients.

James Weinstein, DO, CEO of the Dartmouth-Hitchcock health system, opened the conference by presenting Dartmouth’s success with incorporating quality and outcome measurement tools into daily practice. He noted that the system is moving away from fee-for-service payments and proactively venturing into alternative payment models, such as bundling and episodic care payments.

Value: A common goal
According to keynote speaker Michael Porter, PhD, Harvard Business School, value is the common goal that can unite the interests of all health system participants. Value can be enhanced both by increasing quality and by decreasing costs, and he urged physicians to become leaders in both arenas.

Based on case studies presented by Dr. Porter, delivering excellent care is often less costly, both to providers and to patients. He provided several specific recommendations, including integrating medical practices around patient medical conditions, reimbursing through bundled payments, recognizing excellent providers, and improving the use of information technology in health care.

Several panels of experts provided insight into successful experiments in moving to value-driven orthopaedic care around the country. David Jevsevar, MD, MBA, Intermountain Healthcare, gave a nuts-and-bolts overview of how his organization is tracking quality and efficiency in orthopaedic care delivery. He emphasized that great variations in procedure costs and outcomes exist, even within a single healthcare organization.

According to Jon J.P. Warner, MD, Massachusetts General Hospital, gathering outcome data is useful and valuable not only for improving decision-making but also for conducting high-quality orthopaedic clinical research in the academic setting. Joseph P. Iannotti, MD, PhD, Cleveland Clinic, reinforced the importance of data collection, including readmissions, complications, cost per surgical case, and length of stay.

An integrated care model, which brings together emergency services, physician offices, inpatient services, rehabilitation, and skilled nursing care, relies on data to maximize efficiency and streamline the patient experience. Dr. Iannotti noted that each provider within the group is updated regularly on his or her performance and possible

Various musculoskeletal outcome measurement tools and surveys can be quickly implemented in a practice to track quality. Choosing the right metrics is essential to implementing a quality-improvement program and increasing the value of care in a practice, said Charles L. Saltzman, MD, of the University of Utah.

Bundled payments
Steven F. Schutzer, MD,
provided an overview of bundled payments, also known as “baskets of care.” These payment models are becoming increasingly popular, both with Medicare and private insurers.

Building a bundled payment program in the orthopaedic setting requires a dedicated team of providers, according to Dr. Schutzer. The episode of care needs to be clearly identified, and the costs of providing care need to be determined in detail. Any performance measures to be included in the arrangement should be defined and a means of tracking these measures adopted. Only then should negotiations on pricing the bundle proceed with insurers.

Potential pitfalls of bundled payments include imperfect risk adjustments for complicated patients, unclear definitions and time frames, sharing of potential financial loss, and administrative burdens greater than anticipated. Nonetheless, the potential benefits of aligning incentives, cutting waste, and improving the quality of care to patients make these payment experiments worthwhile to consider.

How do you rate?
Some of the most intriguing presentations were made by representatives from companies that generate and publish ratings of physicians. In the current marketplace, Internet-based consumer information is rapidly transforming how patients select physicians and hospitals.

According to John Santa, MD, MPH, of Consumer Reports, that company will soon be making physician-specific ratings information available to their subscribers. He reported that in a pilot launch of this type of data, Consumer Reports had one of its highest-selling issues in years. This shows, he said, that this type of information is in high demand and physicians should be aware of how it can affect their practices.

Dr. Santa also implored the orthopaedic community to aid in providing data on implants through registries such as the American Joint Replacement Registry. He cited the Society of Thoracic Surgeons as an example of surgeons leading consumer safety; more than 90 percent of cardiothoracic surgeons self-report outcome data, including complications and mortality, which are then risk-adjusted. Such proactive efforts have helped ensure that ratings of these surgeons are both accurate and fair. Consumer Reports now publishes links to these data on their website and is seeking similar arrangements with other medical specialties.

Healthgrades’ Arshad Rahim, MD, MBA, presented detailed information about how his company generates physician ratings. Dr. Rahim stated that orthopaedics has the second-highest number of annual views out of the 170 specialties represented on the site. The top quintile of orthopaedic surgeons each has an average of 172 page views every month on Healthgrades. More than 80 percent of this website’s users have postsecondary educations, and more than half have incomes greater than $75,000.

Many physicians in attendance expressed frustration with Healthgrades, largely because the website does not vet comments that are written on physicians’ profiles by web users. The discussion of these concerns presented an opportunity for Healthgrades to help improve the reliability of its rankings in the future. Dr. Rahim emphasized that physicians should review the information provided about them on Healthgrades and similar websites, correct inaccuracies, and maintain updated, patient-friendly profiles.

Looking forward

Going forward, several challenges to improving value in orthopaedic care will need to be addressed, including the following:

  • Risk adjustment for patient complexity needs to be a component of any reimbursement initiative that is based on quality outcomes.
  • Transparency of healthcare charges and costs must increase to enable patients and insurers to make informed purchasing decisions.
  • The increased momentum toward hospital employment of orthopaedic surgeons threatens private practice groups.

Although integrated health systems make sense in urban areas, forming accountable care organizations or similar integrated arrangements may be difficult in rural areas; as healthcare moves away from fee-for-service reimbursement, physicians who practice in these areas may be adversely affected.

Julie Balch Samora, MD, PhD, MPH, and David B. Bumpass, MD, are the 2012–2013 AAOS Washington Health Policy Fellows.

Editor’s Note: Policy Timeout is a series on advocacy issues written by the AAOS Washington Health Policy Fellows.

Bottom Line

  • Quality and value are rapidly becoming key components of the American healthcare system, and orthopaedics is positioned to be a leader in this process.
  • Choosing the right metrics is essential to implementing a quality-improvement program and increasing the value of care in a practice.
  • Internet-based consumer information is rapidly transforming how patients select physicians and hospitals.
  • To ensure that value-based programs accurately reflect the challenges of orthopaedic practice, surgeons must stay informed and be active participants with hospitals and insurers.