- Monday, April 9, 2018

With changes in health care happening at a pace not seen before in the past century, it is apparent recalcitrant providers of health care services must get serious about appropriate utilization of services and the transparency of how much this service can be delivered. Our patients deserve a coalition of providers who are working collectively together for their benefit of improved clinical outcomes and quality of life.

Thus, it is exciting to see the resurgence of episodes of care or bundled payment models with providers to align the future of our health care ecosystem with better prediction of patient health behaviors, treating with precise clinical care, monitoring the patient’s physical environment and holistic life interactions, and preventing social and economic factors that impair healthy living. As of 2018, 80 percent of states have some value-based payment program in place, and many have multipayer support 1.

One of the largest spend areas in health care is spinal fusion surgery. More than $287 billion was spent on fusion-based spine surgeries in the United States in the first 10 years of the 21st century. By way of example, lumbar fusion surgery accounted for 14 percent of back surgery spend in 1992, but increased to 47 percent by 2003. 2.

Despite these large expenses, there is no consensus on the accepted indications for which spinal fusions are performed. We desperately need more alternatives to spinal fusion surgery to help lower total cost of care for single episodes and at the same time lower total procedural volume due to complications and reinstrumentation.

Value better defined

SonoSpine offers a valuable opportunity in episodes of care management and specifically can target the three most important areas: cost-reduction value, spillover effects, and gainshare for both facilities and physicians.

The establishment of a benchmark price for a bundle or episode of care is typically agreed upon by economic evaluation of historical claims and each provider’s cost and quality performance in the identified time period. In spinal fusion surgery, these costs vary dramatically due to the facility costs at hospitals, physicians’ surgical tools and devices, post-acute care, and related complications within the 90-day period. Among Medicare patients, for lumbar fusion alone, there is a threefold difference in charges billed to the Centers for Medicare and Medicaid Services (CMS) nationwide.

In a recent study published in Spine Journal, variation of episode payments were reviewed for Medicare beneficiaries with three conditions: spinal stenosis, spondylolisthesis and lumbar disc herniation3. The procedures were classified as decompressions or fusions. The authors found that “if payments to hospitals in the most expensive quintile in this study were reduced to the national average per episode of care, a saving of over $162 million could be realized. Additionally, hospitals and surgeons with particularly high rates of fusion-based procedures should consider external benchmarking and recalibration of practice if appropriate.”

I would argue that SonoSpine is the right solution to affix the variable costs in this bundle and provide reliability of outcomes.

Spillover effects

From a Partners Healthcare study in 2014, it was notated that 20 percent of the highest utilizers of health care services spend were found to be from the post-acute area.

This has been the case because of the silos in which providers function and the lack of communication across caregivers. Since the Bundled Payments for Care Initiatives started in the fall of 2013, many improvements have been made with post-acute providers and transitions in care due to their involvement as team members in the Model 2 design. This has led to not only more awareness of where the patient is going but a laser-focus on the right care for the patient at the right location at the right time. For orthopedic spinal surgeries, there is indeed a needed focus in post-acute care for patients since they typically account for 35 percent of total cost.

With SonoSpine, patients and providers receive the right care at the right outpatient facility at the right cost. Additionally, with SonoSpine there is no need for post-acute care to a skilled nursing facility or home health service provider since the patient’s health status improves quickly after the procedure.

With regard to the added spillover-effect benefit, each patient is treated with the same activities, mechanisms, and resources to ensure quality outcomes. In many Accountable Care Organizations (ACOs) or risk-bearing medical groups, there are varying services provided to attributed versus non-attributed patients based on the performance contract incentives or methods of reimbursement. This can lead to a negative spillover effect for non-ACO patients.


Gainshare opportunity

Finally, by leveraging bundled payments through efficient clinical pathways, providers can share in the financial savings by helping ensure prompt follow-up care for patients during the post-operative period. Patient engagement is important throughout a measured time period specifically to ensure proper utilization of services — and the quickest route to recovery.

The referral relationship between specialists and primary care providers or allied professionals, such as chiropractors, can be strengthened through defined pathways for spinal care when all are focused on the precision treatment that is best for the patient. Specifically, for the orthopedic population, this warrants participation in nonsurgical approaches before moving to a surgical option.

Within SonoSpine, this type of patient-centered approach brings value to the patient, their family, and the providers that seek the expertise to solve for debilitating chronic back problems. Holistic management of the population leads to long-term effects for the community, longevity for the financial arrangement, and trust between providers.

Scott W. Disch, MPH, is President & CEO of SolveMed Consulting, LLC. He has worked in acute care hospitals and ambulatory health networks for the past 20 years with a focus on administration and operational management of physician practices, strategic growth initiatives, population health/risk contract management, and development of physician financial and service contractual relationships.

1 Excerpted from: VBP News, Volume 3 Issue 6, March Second Edition 2018, “M2HCC: ‘Nearly Every State’ Engaged in Value-Based Payment.”

2 Rushton A, Staal JB, Verra M, et al. “Patient journey following lumbar spinal fusion surgery (LSFS): protocol for a multicentre qualitative analysis of the patient rehabilitation experience” (FuJourn) BMJ Open 2018;8:e020710. doi: 10.1136/bmjopen-2017-020710.

3 Gologorsky Y, Knightly JJ, Chi JH, Groff MW. “The Nationwide Inpatient Sample database does not accurately reflect surgical indications for fusion.” Journal of Neurosurgery: Spine. 2014;21(6):984-993. Epub 2014 Oct 17.

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