Outcome Based Liability Ready or Not!…Ideal Treatment or Best Value?…Epidural Steroid Injections on Hold? and More…
Here Come Outcome Based Financial Liabilities – Ready or Not!
David J. Jacofsky, M.D. is an orthopedic surgeon and the Chairman of The Center for Orthopedic Research and Education (CORE) in Arizona. He is also a SHRI Senior Scientist and Head for SHRI/CORE Orthopedic Research Lab. He tells OTW, “I don’t think that all orthopedic surgeons are fully aware of reality of changes that are coming regarding payor reform. Many doctors lack the infrastructure to be able to be successful in a world where we have to directly manage costs and take significant financial risk on our complication rates, the post discharge period, and on readmissions for any reason. How many surgeons and hospitals really have a deliberate, automated, and coordinated effort to follow evidence based protocols? Hip and knee arthroplasty are the best examples in healthcare of how bundled payments for the full episode of care can be piloted. It’s a very distinct surgical procedure, it’s planned and elective, and there are significant societal costs associated with them that are largely in control of the provider (patient selection, implant costs, length of stay, whether a patient is discharged home or to a skilled care facility, preoperative optimization, preoperative education of the patient and preparation of family members who can assist with aftercare, etc.).”
“Because it is a distinct episode of care, unlike more chronic and variable conditions such as congestive heart failure or diabetes, it is easy to tell the doctor that they are fully responsible for all the patient costs from three days prior to surgery until 90 days post-discharge. If you send the patient to a nursing home you are effectively paying for it, as you or the hospital receives the same fixed total dollar amount for a given episode of care. The good news is that there is a significant opportunity for doctors to see an increase in income based upon taking a financial risk with these sorts of procedures if they are prepared.”
“Our group has seen an increase in reimbursement rates for four years because we are able to take outcomes-based risks. We tell the insurance companies, we will take a marked reduction in guaranteed reimbursement at the time of service, i.e., instead of paying ‘x’ for a knee replacement you pay us half up front, BUT, here are ten quality metrics and if we hit these targets for each of them then we save the insurer this amount of money. We want half of that. This is working very well for us. Admittedly, we are a larger practice of 50 doctors and 26 physician assistants. As always, there is strength in numbers, but the key lies in a coordinated strategy and the creation of an infrastructure to make such pay for performance programs viable. We are hopeful that smaller groups will continue to partner with us to improve the ability of physicians to ‘take health care back.’”
Ideal Treatment or Best Value?
Anthony Romeo, M.D. is an orthopedic surgeon at Midwest Orthopaedics at Rush. He is also Professor of Orthopaedic Surgery at Rush University Medical Center, and director of the Section of Shoulder & Elbow. Dr. Romeo tells OTW, “A recurring theme now in all aspects of orthopedic surgery is the movement toward determining the value of healthcare. At the recent American Shoulder and Elbow Surgeons (ASES) meeting we spent a lot of time discussing how that applies to us. There is an increased emphasis on our role as orthopedic surgeons in helping to define the value of care that we provide. The ASES has done a great job of looking at outcomes that define care in terms surgeons are comfortable with. However, we must get better at defining this value in a way that patients understand. Why? Because there are a number of players at the table, including insurers, government, and other third party reviewers. The most alarming part is that these reviewers—who are most often NOT orthopedic surgeons—don’t often understand the value of the care we provide. And because to date we have had a hard time describing it they go about making decisions based entirely on cost. We need our patients as allies and advocates. Patients can request and lobby for care that is valuable for them.”
“For example, we are really under siege with regard to reverse shoulder arthroplasty. It is twice as expensive in terms of implants as compared to a standard total shoulder, but the coding and billing result in the same reimbursement in insurance. Then we are told, ‘Well, since you haven’t shown that it’s valuable why should we pay the extra cost?’ It’s maddening because we know without question that a reverse shoulder is the ideal treatment for arthritis combined with a nonfunctioning rotator cuff. There is no better operation for those who fail conservative management. While a standard total shoulder may have good pain relief it is more likely to be ineffective as far as the ability to perform daily life activities. The solution is to collect the proper outcome data before surgery, including patient specific satisfaction scores and quality of care scores like those used in Europe. And, we need to do a better job of presenting our data.”
Career Debut: Some Tips
Scott Tucker, M.D. is winding up his last year of residency and next year will begin a fellowship at the Andrews Institute for Orthopaedics and Sports Medicine. We’ve followed Dr. Tucker through his years of training and check in with him now as he winds up his formal education and prepares to embark on his career. He tells OTW, “I know that hospital employment is increasingly popular, but honestly, my contemporaries are leaning toward private practice. Many people say, ‘Join a hospital…you’ll have more security.’ But maybe it’s because we’re emerging from training with around $300, 000 in debt that we’re willing to take our chances with private practice. There is more risk, but there is also a much higher earning potential.”
“As for how I will approach practices next year, I honestly wish that we were given more guidance on this in residency. However, I have heard from many who have gone before me that when considering a practice it is important to ask to see their books. It’s easier for me to say that now, but when I am sitting across the table from the senior partner it might be a bit harder. The older doctors I know, however, say, ‘You will eventually become a partner, so it is reasonable to make this request.’ I also plan on asking about how best to market myself, how much call I would be taking, and, perhaps most importantly, how long does it typically take to get one’s practice to the level where you’re doing the kind of surgery you set out to do.’ I’ll keep you posted, Elizabeth.”
Epidural Steroid Injections on Hold?
Alan Hilibrand, M.D. is a professor of Orthopaedic Surgery and Neurosurgery at the Rothman Institute in Philadelphia. He is also Director of Medical Education for the Department of Orthopaedic Surgery at the Rothman Institute and Jefferson Medical College. Dr. Hilibrand tells OTW, “I think it’s fascinating that people are taking a second look at the role of epidural steroid injections in the treatment of spinal disorders. This is to a great extent due to the recent fungal meningitis outbreak…and while this could happen with any injection, when it involves an injection where the benefits are unclear it becomes more of an issue. The other reason that orthopedic surgeons are questioning this treatment is because of a recent study that we published looking at the option of using these injections on weekend warriors with spinal stenosis. It looks like this treatment option is not as effective for individuals with spinal stenosis as with those who have a herniated disc. In cases involving a herniated disc people often get better so you are quieting down pain and giving them a chance to get better on their own. For spinal stenosis epidurals are used to help avoid surgery, thus it’s more of a temporizing measure. Our study suggests that epidurals may not be benefitting people in significant way in terms of functional outcomes or in preventing surgery.”
“Patients themselves are coming into our offices at Rothman and saying, ‘We’re not so sure about epidurals anymore.’ We surgeons do feel a compulsion to offer people nonoperative treatment before surgery, but at this point we are becoming less likely to recommend steroid injections. We need answers in the form of a prospective randomized trial comparing operative care to these injections. This is often difficult because patients come in with their own preferences for a certain treatment. I don’t see us altering course in the next year or so unless we can get some data that makes us more comfortable recommending this nonoperative treatment. Until then, there will increasingly fewer epidurals.”
Darren Johnson, M.D. Named Team Physician of the Year
University of Kentucky (UK) team orthopedic surgeon Dr. Darren Johnson has been named the 2012-13 Southeastern Conference Team Physician of the Year by SEC member institution athletic training staffs. This award is chosen by the athletic training staffs at SEC member institutions and is given annually to recognize a team physician who has contributed greatly to his or her school’s teams and to the SEC sports community. Voting criteria includes reliability to the physician’s athletic department and noted involvement in the field of sports medicine. A $1, 000 award will be given to the University of Kentucky Athletic Training Education Program in Dr. Johnson’s name for student athletic trainer scholarship or education.
Currently, Dr. Johnson serves as the chair of the Department of Orthopaedic Surgery and Sports Medicine at the University of Kentucky and the head orthopedic surgeon for UK Athletics. Dr. Johnson earned his degree from the UCLA School of Medicine before doing his residency at the University of Southern California and his fellowship at the University of Pittsburgh.
