The Gainsharing Arrangement
The deal with the neurosurgeons was that they could be paid a share of three years of cost savings attributable to changes the neurosurgeons made when selecting and using products for their spinal fusion surgeries.
For example: before gainsharing, the neurosurgeons used BMP2 in 29% of their cases. After gainsharing, the neurosurgeons set guidelines to reduce BMP2 usage to no more than 4% of the cases.
At the beginning of the program the administrator collected, measured, and analyzed supply costs, quality of patient care, and utilization on a national level and compared it to actual experience at the medical center and came up with a total of 34 cost-saving changes.
Everyone (the medical center and the neurosurgeon group) reviewed the cost savings recommendations for medical appropriateness—which entailed looking at FDA guidelines and clinical research information.
Following that, the medical center then asked the neurosurgeons to make certain operating room changes for spinal fusion surgeries. There were two major change categories.
- Use Bone Morphogenetic Protein on an As-Needed Basis – Three recommendations suggested that the neurosurgeons use bone morphogenetic protein (BMP) only on an as-needed basis for surgeries performed on three specific regions of the spine. The neurosurgeons had conducted a comprehensive medical review of BMP and were careful to ensure that any reduction did not affect quality of care.
- Product Standardization – Thirty-one recommendations suggested that the neurosurgeons standardize spine fusion devices and supplies. That triggered a vendor and product review and a three-step product evaluation process. All the neurosurgeons agreed to use the preferred products where medically appropriate.
Along with these product change recommendations, the gainsharing Arrangement also set up patient quality of care monitoring and documentation in order to protect against inappropriate reductions in services.
The medical center also organized an oversight committee (The Program Committee) from medical center representatives and the neurosurgeons.
The program administrator reported—not to the neurosurgeons—but to the Program Committee and kept everyone up to date regarding product costs and patient care quality measures.
To reduce the possibility that a surgeon would cherry-pick patients, the surgeons were prohibited from selecting patients to participate in, or withdrawing patients from, the Arrangement.
To enforce these restrictions, the Program Committee periodically reviewed patient age, case severity and payor data in order to confirm a historically consistent selection of patients.
The penalties for not complying with the rules were simple—expulsion from gainsharing.
