“That has never worked,” Porter said. “We have to change the structure of how we deliver health care and how we think about health care.

“The starting point in fixing the problem is to deliver value for the patient. That will require better outcomes that matter to the patient and are relative to the total cost of delivering those outcomes.”

Porter emphasized the need to break the silos between the various medical specialties, as well as among hospitals and insurers.

There are two types of value-based reimbursement — capitation, such as ACOs, and bundled payment. Because bundled payment focuses on a full set of services needed over the cycle of treating a condition, it offers the best value while continuing to reward physicians.

Porter’s speech reflects the spirit behind the Interdisciplinary Conference on Orthopedic Value Based Care. Our next conference is scheduled to take place on January 18-19, 2019. This conference aims to bring together orthopedic surgeons, anesthesiologists, orthopedic nurses, hospitalists, CRNAs, hospital executives, OR directors, orthopedic executives and many others. The conference will be held at the Fashion Island Hotel in Newport Beach, CA and will include 3 tracks to address the clinical, operational and financial issues of value based care for the orthopedic patient.

For information on our recent 2018 conference, including speakers, sponsors and schedule visit our website.

Our 2019 conference is currently in the works and more information will be provided as soon as details are finalized.

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For those of you who have not attended the previous two conferences, here is a recap of of our inaugural 2017 event:

An exciting new conference arrived to Newport Beach, California in January 2017. Attendees were part of a groundbreaking “immersion weekend” that brought together hospital executives and clinicians who are involved in the care of the orthopedic patient.

The “Interdisciplinary Conference on Orthopedic Value-Based Care” focused on orthopedic bundled payments, Perioperative Surgical Home and Enhanced Recovery, and the team approach critical to success. This multidisciplinary conference strives to gather ALL healthcare providers and administrators involved in the episode of care of an orthopedic patient.

I interviewed some of the conference speakers to get their perspectives on the event:

Catherine MacLean, MD, PhD is Chief Value Medical Officer at Hospital for Special Surgery (HSS) in New York City. Dr. MacLean leads the Value Management Office, an established group focused on improving the way HSS defines, measures, and achieves value. Dr. MacLean leads the efforts to improve external quality transparency, giving consumers and other key stakeholders the information they need to make informed care decisions.

Dave Janiec is the Director of Contracting at Rothman Institute. He is involved in all facets of payer contracting, but the focus of his work is assisting the 140 doctor practice in its transition from the traditional fee-for-service care model to the value-based care model. He is actively involved with payers–government, insurance and employer–engaging in Alternative Payment Model development and implementation. He is responsible for performance measurement of clinical activity pertaining to all APMs and regularly meets with clinical staff to communicate all current program guidelines and available performance data.

Editor: Why are you excited to be a part of this new and innovative conference?

Dave Janiec: Healthcare has changed and continues to change, particularly as pertains to alignment of interests (payors, providers, patients). Movement from a transactional model to a true patient-level (value) model is a huge undertaking and not one that can be accomplished overnight. A forum, as this one, that encourages discussion and collaboration among formerly independent parties is important.

Dr. MacLean: The creation of value requires a team effort, both in terms of delivering the the highest quality are and in doing that efficiently. The conference is focused on this important team concept, bringing together all the different people that deliver care across the care episode for total joint arthroplasty.

Editor: Give me a sneak peek of your sessions – what can we expect?

Dave Janiec: My sessions are in two coordinated parts and will discuss 1) understanding the CJR model and considerations in adopting it, and 2) how to use data from an entity’s own systems to improve performance once in the model.

Dr. MacLean: I will share my perspective on the evolving value policy landscape as it pertains to musculoskeletal care and how HSS is responding. I will also share insights into the on-the-ground production of high quality, high value care including the importance of personalized health management.

Editor: Why do you feel these topics are important?

Dave Janiec: Rothman Institute is currently participating in BPCI Model 2, has bundled payment and shared savings arrangements with two commercial payers, will be adding a third in the first quarter of 2017, and expects to be onboarding another by second quarter 2017. All bundled payment and shared savings programs incorporate quality benchmarks. Interestingly, by design, episodic care is self-regulating in terms of quality, because the provider is held accountable for the cost of a patient’s care through a 90-day post-acute period; poor quality care or insufficient care is actually far more costly than proper care (as a result of complications, readmissions, emergency room visits, etc.); that said, cost isn’t a transparent indicator. Quality metrics clearly evidence the results of proper care pathways, and as well, evidence realistic limits on cost reduction. Proper bundled payment management cannot occur without ongoing clinical input.

Dr. MacLean: Peri-operative optimization is critically important to optimizing patient outcomes. This includes pre-hospitalization care, pre-operative care in the hospital, post-operative care in the hospital, and post-acute care after discharge. While this is important for all surgical procedures, there is bigger mandate and opportunity to utilize the pre-hospitalization period to drive optimal outcomes for elective procedures such as total joint arthoroplasty.

Editor: What future do you see for your organization in 2017 and beyond?

Dave Janiec: It is clear that bundled care is not going away. It is also clear that there is a finite period of time during the transition from fee-for-service to value that payers and providers will be on a learning curve, after which period the true cost of various services will be known and reimbursement can and will be established; most, if not all, risk for the cost of care will be transferred to the provider. Successful management of episodes of care will become a part of the business model of every practice out of necessity.

Dr. MacLean: We will continue to refine the important care pathways that have been implemented at HSS to optimize care. Additionally, we are incorporating the routine collection of patient reported outcome measures (PROMs) into clinical care. Data on these PROMs will be essential to our ‘learning delivery system’ and help us to better understand how specific elements of the care we deliver impact outcomes that are important to our patients.

Editor: Anything else you think people should know?

Dave Janiec: There is nothing about the current environment in healthcare that has been vetted and cast in stone. Not unlike episodic care, the approach must be collaborative. There is a lot of knowledge around and many resources being allotted to bundled care but no one has all of the answers at this stage.

Dr. MacLean: Along side the important work that care providers are doing to improve value, we need to be mindful of the need to develop meaningful quality measures that accurately represent the quality of the care we provide. Otherwise, value will be defined largely by cost.

These are just two of the 21 nationally-renown multidisciplinary faculty that presented at the conference in January 2017.

2018 Event: Schedule, speakers and partners information are currently available at our VBC Conference website.

2019 event: Program and speaker details are coming soon.

The post The Future of Ortho Value-Based Care appeared first on Dr. Zeev Kain.

Experts like the consultants at Sg2 have been predicting the rise of outpatient joint replacements for many years, and their recent data has been showing an acceleration of the trend, with 2012 to 2015 showing a 47 percent increase in procedures nationally.

In September the agency received comments from both sides of the industry. Hospital groups expressed concerns, as joint replacement surgery usually represents a large profit center within the institution. Surgeon practices and ASC leaders promoted the move.

This month CMS finalized moving knee replacement off the “inpatient only” list so it can be performed on Medicare patients in ambulatory surgery centers (ASCs) in the future. Hospitals that do not have an outpatient surgical setup have been seeking to acquire surgery centers or form joint ventures with them to capitalize on the movement.

Hospital teams will need to learn three new key skills to embrace this trend and prepare to do outpatient joint replacements:

Regional Anesthesia Techniques

If your anesthesia teams are not prepared to use the most advanced regional anesthesia approaches for joint replacement surgeries, a program cannot succeed. These new protocols for pain management is what allows patients to get up and move after surgery and go home the same day.

Team Coordination

Minimal time with the patient “in house” means all your efforts have to be highly coordinated across the team to maximize efficiency and ensure discharge happens on schedule. There’s no time to be wasted waiting around for medication, equipment or staff resources for education or therapy.

Intense Patient Management

Resources to prepare the patient pre-surgery and support the patient post-surgery from home must be in place. Intense pre-op selection, optimization and education can help improve outcomes, while post-op support prevents ER visits and readmissions.

At our past 2018 Interdisciplinary Conference on Orthopedic Value-Based Care attendees participated in a pre-conference bootcamp on outpatient joint replacement led by pioneers from Hoag Orthopedic Institute. The team at Hoag was one of the first in the country to implement an outpatient joint replacement program at their surgery center. At our conference, they shared lessons learned and best practices to get new programs off on the right foot.

Our next Interdisciplinary Conference on Orthopedic Value-Based Care will be taking place on January 18-19, 2019 at the Fashion Island Hotel in Newport Beach, CA. 

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Background

The American medical environment is currently experiencing a dramatic transformation and much of that relies on the Patient Protection and Affordable Care Act (ACA) and Triple Aim initiative. The Triple Aim was developed by Don Berwick of the Institute for Healthcare Improvement (IHI) in 2008 and focuses on revolutionizing US healthcare through three main tenets: (1) improving individuals’ experience of healthcare, (2) improving the health of an aging US population and (3) reducing the ever-rising per capita costs of healthcare. The ACA of 2010 has significantly altered the American healthcare system, shifting priorities to emphasize the greater importance of patient-centered outcomes. In that context, the ACA mandated public reporting programs that incorporate information collected using the Consumer Assessments of Healthcare Providers and Systems (CAHPS®) surveys. Recently the CMS has introduced the OAS CAHPS (Outpatient and Ambulatory Surgery Survey), which aims to improve quality of healthcare in the perioperative space and to measure patient experiences with surgeries performed at hospital outpatient surgery departments or ambulatory surgery centers. The purpose of this article is to briefly review the history of the development of the various CAHPS surveys and to describe the OAS CAHPS.

History of the CAHPS

The history of the CAHPS dates back to 1995 when the first survey that was created by the Agency for Healthcare Research and Quality (AHRQ) in conjunction with the Center for Medicare and Medicaid Services (CMS). According to the CMS and AHRQ, the CAHPS survey goals are: (1) “To develop standardized surveys that organizations can use to collect comparable information on patients’ experience of care” and (2) “To generate tools and resources to support the dissemination and use of comparative survey results to inform the public and improve health care quality”[i]. While numerous studies have reported the high reliability and validity of the CAHPS surveys, many clinicians criticize these surveys and indicate that the questions presented in the surveys are not clear and that attribution to individual specialty or physician is very difficult.

The OAS CAHPS Survey

The OAS CAHPS survey is aimed to measure the experiences of patients who received care in Medicare-certified hospital outpatient departments or ambulatory surgery centers. Specifically, the aim of the survey is to measure patients’ perspectives on constructs that are important (for patients) when choosing a facility for their care. The development of the OAS CAHPS has been underway since 2012 and an initial test was conducted in 2014 (24 facilities) to assess validity, reliability and implementation procedures. Following the initial testing, OAS CAHPS was revised and, in 2015, a second round of testing was conducted. The survey received accreditation as a CAHPS® survey in February 2015. The second round of testing was particularly important as its aims were to assess data collection and develop models to adjust for patient characteristics prior to public reporting. This later aim is highly important since it is well known that certain social characteristics bias the responses to CAHPS surveys and, therefore, a process of “statistical adjustment” has to be done prior to comparing an individual center to national benchmarks. Many more details regarding the development and implementation can be found at the www.OASCAHPS.org site. It is important to note that currently there is not a specific timeline for linking OAS CAHPS performance to reimbursement.

The OAS-CAHPS survey will be given to adult patients who had specific procedures or surgeries (based on a list of CMS-approved CPT codes and G codes). These procedures have to be performed in a Medicare-certified Hospital Outpatient Department or a Medicare-certified freestanding ASC; overnight-stay patients are included. Patients are only eligible to receive the OASCAHPS survey once every six months. HOPDs or ASCs can apply for exemption from mandatory OAS-CAHPS if they have 59 or fewer OAS CAHPS eligible patients annually. The OAS-CAHPS survey must be administered by an independent. CMS-approved vendor and can be administered by mail, telephone or a combination of mail with a telephone follow-up.

Timeline

In January 2016, CMS began voluntary, monthly data collection using the OAS CAHPS survey tool. The initial plan was for CMS to begin public reporting in January 2018, based on the OAS CAHPS data collected between July 2016 and June 2017 of the voluntary participation period. CMS did indicate that facilities will be able to request that their voluntarily collected OAS CAHPS data be suppressed from public reporting during the preview report period.

On July 20, 2017, however, the Federal Register published a new proposed rule for the OAS CAHPS. In this latest Proposed Rule, CMS proposes to delay the implementation of OAS CAHPS to 2020 payment determination (2018 data voluntary data collection). If approved, this means that OAS CAHPS would continue with the voluntary reporting throughout 2018. The rationale provided for the delay is to enable CMS “to analyze the national implementation data and consider any necessary modifications to the survey tool and/or CMS systems and review the regulatory burden for providers and investigate strategies to reduce the burden before making a determination of timing for future implementation.” “The delay will allow additional time for participating facilities to identify a survey vendor and work through. For those of us that hope that this CAHPS measure will simply go away, the CMS indicates that “CMS continues to believe that the OAS CAHPS Survey addresses an area of care that is not adequately addressed in the current measure set and will be useful to assess aspects of care where the patient is the best or only source of information. These measures will enable objective and meaningful comparisons between hospital outpatient departments and ambulatory surgery centers.”

References: 

[1] https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Hospital_VBPurchasing_Fact_Sheet_ICN907664.pdf [Accessed 02-13-2017.]

Hargraves, J. L., Hays, R. D., & Cleary, P. D. (2003). Psychometric properties of the Consumer Assessment of Health Plans (CAHPS®) 2.0 Adult Core Survey. Health Services Research, 38(6 Pt 1), 1509-1527.

Darby C, Hays R, Kletke P. Development and evaluation of the CAHPS Hospital Survey. Health Serv Res 2005;40;1973-1976.

http://www.hcahpsonline.org/home.aspx [Accessed 2-13-2017.]

Hargraves JL, Wilson IB, Zaslavsky A, et al. Adjusting for patient characteristics when analyzing reports from patients about hospital care. Med Care. 2001; 39:635–641

Thi PLN, Briancon S, Empereur F, Guillemin F. Factors determining inpatient satisfaction with care. Soc Sci Med. 2002; 54:493–504.

Agency for Healthcare Research and Quality, “CAHPS Glossary,” https://cahps.ahrq.gov/about-cahps/glossary/index.html)

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