The Patient Protection and Affordable Care Act includes three critical pillars: quality, patient safety and cost. Medical homes, accountable care organizations, bundled payments and capitation — all three tenets are prominent in new care delivery and payment models popular today.
"That's a very positive change in healthcare and has significantly benefited spine surgeons because safety is their number one concern," says Alexander R. Vaccaro, MD, PhD, President of Rothman Institute in Philadelphia. "Spine surgery has an inherent risk of adverse events in the operative and perioperative theater. With an emphasis on quality and safety, we've been able to minimize preventable adverse events."
Healthcare reform refocused many providers to patient outcomes metrics, including the HCAHPS, sponsored by the ACA. Once per month, Dr. Vaccaro and his colleagues gather to review each physician's scores and the hospital's overall scores to see where they can provide better patient satisfaction and experiences.
"We also have internal metrics where we do a survey to ask patients about their experiences with our physician offices and ASCs," he says. "That gives us a tremendous amount of data because as we've seen, good patient experiences often result in patient referrals from both the referring physicians as well as the patients themselves."
The satisfied patient has the potential to refer other patients to their practice, but for every unsatisfied patient Dr. Vaccaro estimates they lose three to five patients or more by non-referrals and negative publicity. The surgeons also track:
• Adverse events
• Neurologic injury
• Dural tears
• Wound infection
• Failure to progress along the expected postsurgical care pathways
• Hospital readmission rates
"We collect that information and compare it to normative data to make sure we're above average," says Dr. Vaccaro. "We take this information and share it with the referral doctors, hospital systems and insurance companies and use that in our negotiation process to optimize reimbursement and approval for patient surgeries."
The surgeons are then able to compare their data against others and show they provide better-than-average care. They can use this data in discussions with referral physicians, hospital systems and insurance companies to gain approval for surgery and optimize reimbursement.
Matching patients with the appropriate hospital or surgical facility and findings less expensive implants are the low-hanging fruit for lowering the cost of care, and can be the most effective ways spine surgeons directly impact care. Shortening the hospital length of stay with less invasive procedures — or taking patients into the outpatient setting when possible — significantly lowers the cost for an episode of care. Implants account for a large portion of healthcare costs as well, and many devices exist for standard procedures at various price thresholds. But there are risks involved.
"The most important thing is to make sure you understand the quality of the implants you use and don't be sucked into using devices because they are cheaper," says Dr. Vaccaro. "Make sure you understand its FDA-approval status. Never cut corners and use your primary guiding principle as patient safety and outcomes first."
Quality has always been top-of-mind for most spine surgeons, but cost is a relatively new point of focus. Surgeons are paying more attention as they experiment with bundled payments, ACOs and other risk-sharing payment models.
There are ways to cut corners that do not compromise quality. Insurance companies will also pay more attention to outcomes for their members and insist providers maintain a certain level of quality and outcomes; Physicians can manipulate the cost curve while at the same time making sure outcomes do not fall below a certain level of quality.
"In order to participate, we have to know what our costs are. That begins with dashboards in the operating room where we can compare our costs for standardized procedures — statewide and nationwide — and make sure we are competitive across the board," says Dr. Vaccaro. "We are dealing with a finite amount of resources available and the only way to maintain a margin is to make sure the supply chain is more efficient and we've minimized the costs that can be minimized without having a direct impact on patient outcomes or safety."
But all this takes work. Without basic knowledge of benchmarks and individual data, spine surgeons will be cut out of the equation.
"If a spine surgeon has a voice in the creation of bundled payments and the ACO partnership, that will be very beneficial for them," says Dr. Vaccaro. "The spine surgeons can't be a passive participant to be lost in the negotiations."
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Looking back: 4 spine surgeons discuss important professional lessons
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