With implementation of the Affordable Care Act, change has become the byword for the U.S. healthcare system. The way physicians deliver and get paid for healthcare services is changing, and many physicians have shifted from private practice to hospital employment. These changes—as well as the expectation of additional changes—concern many practicing orthopaedic surgeons. They also create the need for us to lead and manage our practices in new ways.
As orthopaedic surgeons, we need a new set of competencies to guide career paths and manage our businesses. Whether in practice or graduating residents, we are faced with several challenges and decisions. Should I go into (or stay in) solo practice? Should I join (or merge with) a small or large specialty group? Should I become employed by a hospital? Each of these decisions has its pros and cons.
Regardless of practice decisions, we are facing changes in how we are paid for our services. Payment for value and quality is replacing the traditional fee-for-service model. Many employers are beginning to use quality metrics in determining a portion of physician reimbursement. Bundled payments that provide a negotiated payment for the total episode of care are becoming the norm.
Both private insurance companies and government healthcare plans are increasingly requiring that we track patient outcomes. In 2013, 70 percent of the measures used to determine quality were process-oriented; 30 percent were based on patient satisfaction. Beginning this year, 25 percent of quality of care measures will be based on outcomes, 30 percent will be based on patient satisfaction, and just 45 percent will be based on processes. Who determines what quality measures are used—and how those decisions are made—is critically important.
Data collection tools
The AAOS has made determining these measures a priority through its Council on Research and Quality and its Committee on Evidence-Based Quality and Value. Clinical practice guidelines, appropriate use criteria, and other tools have been developed to help us improve quality. Performance measures are next.
In addition, several validated, disease-specific instruments are available for tracking outcomes. How we obtain those data is extremely important. If we do not track our own outcomes, private insurance companies and the government will track the data for us. What payers tend to track may not be pertinent to the way we practice. If we do not have the right data collection and analysis tools, tracking and reporting our own data will become cumbersome, costly, and time-consuming.
What data are needed? How will they be collected? Many traditional outcomes instruments have been shortened in an effort to improve their usefulness, so we now have the QuickDASH and the SF-12. More recently, technology has become available to facilitate our ability to track outcomes. The National Institutes of Health spent 10 years and more than $10,000,000 developing the Patient-Reported Outcomes Measurement Information System (PROMIS). This computer-adaptive testing module is efficient, basing each subsequent question on the response to a previous question. More information on PROMIS can be obtained at www.nihpromis.org
Several commercial products for tracking outcomes are also available. Some are freestanding, while others are compatible with various electronic health record systems (EHRs). Outcomes instruments from the Advisory Board, Ortech, Oberd, InVivoLink, and Socrates are becoming widely used. Even orthopaedic implant and equipment companies have developed outcome data collection tools.
Many systems rely on patients inputting data in the physician’s reception room or online using a patient portal. Many data collection software programs work with EHRs for inputting or mining data. Some have different modules for tracking patient outcomes in the clinic and in the hospital and are capable of generating operative reports and clinic notes.
Many programs send educational material and automatic reminders at user-determined intervals. Most programs are customizable and many measure patient compliance. These programs can often track patients in outpatient therapy, home health, and skilled nursing facilities and can trigger alerts if patients answer online questions in certain ways or are not compliant.
At least one general database mines data directly from hospitals and clinics. It provides cost and quality data and compares severity-adjusted performance profiles among similar institutions.
Some data collection tools will track implant inventory, suggest implant types based on patient risk factors, and track outcomes against de-identified benchmarking data. In addition, data may be exported to national joint registries, and databases may be queried for research or quality management projects. Patient education and shared decision-making features may be included in some programs.
According to Michael Porter, PhD, of the Harvard Business School, “Measuring, reporting, and comparing outcomes are perhaps the most important steps toward rapidly improving outcomes and making good choices about reducing costs.” Getting the right data, in a format that can be quickly and easily interpreted is paramount; we don’t have the time to sift through mountains of data.
Data must include outcomes important to clinicians as well as what is relevant to the patient. A 20-degree improvement in motion at the proximal interphalangeal joint may seen significant to the clinician, but if the patient still cannot perform activities of daily living, the desired outcome has not been attained. The data should be tracked for sufficient time to evaluate long-term outcomes and should include enough information to enable risk adjustment.
Measuring and studying our outcomes is important for improving quality of care and decreasing costs. We can only improve when we understand our outcomes.
Frederick N. Meyer, MD, is a past member of the AAOS Practice Management Committee and the course director for the Information Technology (IT) Demands for Orthopaedic Surgeons precourse seminar on Thursday, Sept. 11, 2014.
Learn more about data and outcomes
The 9th Annual AAOS Practice Management Meeting, “Tomorrow is Closer Than You Think,” is being held Sept. 11–13 in Chicago. It includes a half-day workshop focusing on the link between data and outcomes and how information technology creates the capacity for orthopaedic surgeons to collect and analyze their practice.
For course and registration information on the 9th Annual AAOS Practice Management Meeting, including the half-day workshop, visit www.aaos.org/courses