What’s Important: Preparing for the Transition to Value-Based Health Care

Field: Health Professions (Health Sciences)

In today's health-care environment, advances in biomedical science have allowed us to achieve unprecedented success in diagnosing and treating human illness. However, we also face enormous challenges. Per capita spending on health care in the United States is substantially more than that of any other developed country and continues to rise, while patient outcomes and the health of the U.S. population do not reflect that higher cost of care. There are many reasons for this. The fee-for-service payment model emphasizes "care" (volume and intensity of services) over "health." Lack of interoperability and coordination across the health-care system leads to higher costs, increased burdens on patients, and inefficient use of provider time. For example, not a week goes by that I don't repeat an imaging study or laboratory test that was performed on the same patient within the past week simply because I cannot access the results of the previous test. We also have a culture of defensive medicine, which leads to overutilization of unnecessary tests and procedures. Providers are engaged in a vigorous medical "arms race," constantly trying to outdo each other by using newer, more advanced technology, with little or no evidence of improved outcomes. Finally, the disconnect between the people who consume health-care resources (patients and physicians) and those who pay for it (employers and government) creates a moral hazard. However, the primary driver of dysfunction in the U.S. health-care system is the lack of competition based on "value," where value is defined as patient-centered health outcomes per health-care dollar spent. The recognition of these challenges and the demand for better health-care value are leading to rapid changes. By March 2016, the Centers for Medicare & Medicaid Services (CMS) had already reached its 2016 goal of tying 50% of Medicare spending to alternative payment models, and was well on its way to achieving the goal of tying 80% of spending to alternative payment models by 2018. To achieve the goal of delivering value to patients, stakeholders need transparent, actionable data on cost and outcomes that can be used to identify opportunities for improvement. Secondly, incentives need to be reorganized around patient-centered value, with providers and patients taking on increased accountability for outcomes. Finally, strong leadership from physicians is needed to drive these changes and to develop a culture of perpetual learning, characterized by the constant evaluation of results to optimize value. Empowering Stakeholders with Actionable Data In orthopaedic surgery, the most important patient outcomes are pain and function. Yet, very few practices systematically measure pain and function in their patients using validated patient-reported outcome measures. Patient-reported outcomes should be used routinely for shared medical decision-making between the patient and the provider to identify the best treatment plan based on each patient's values and preferences. Physicians often ask me why they should collect outcomes data since that has not historically been part of their practice. The answer is simple: without tracking outcomes, it is impossible to understand where the opportunities are for improvement. To continuously improve our outcomes, orthopaedic surgeons need access to real-time information regarding patient-reported, clinical, operational, and financial outcomes. Once the care team defines a set of performance measures, they must work with health-system administrators to develop the technology infrastructure and the tools to efficiently capture patient outcomes before, during, and after treatment, and to convey the information in real time. To reward practices that provide the greatest value, patients also need access to meaningful provider-level outcomes data that are easily interpretable, objective, and risk-adjusted. Currently, even for patients who are highly motivated to seek information regarding provider quality, the data can be difficult to access or interpret, or are simply unavailable. Reorganizing the Delivery and Payment System Around Patient-Centered Value The current organization and experience of medical care is provider-centric, with specialists organized by anatomic region, disease processes, or services provided. Under this structure, bolstered by fee-for-service incentives, musculoskeletal providers (including orthopaedic surgeons, physiatrists, rheumatologists, and physical therapists) frequently work in "silos," and have few incentives to coordinate care for their patients. Moving from a singular focus on technical skills to managing patients across the continuum of care requires reorganization around the conditions we treat, such as arthritis or injury, by bringing together all providers involved in an episode of care. Instead of requiring the patient to navigate a confusing, uncoordinated system of providers who cannot easily communicate and share information, often leading to duplicative or unnecessary care, the patient should be able to access a multidisciplinary care team, co-located to whatever extent possible, with a common information platform to enable seamless communication. This team of providers could include an orthopaedic advanced practice provider (i.e., nurse practitioner or physician assistant), an orthopaedic surgeon, a physiatrist, a physical therapist, a nutritionist, and a behavioral health specialist or a social worker. This model focuses on "downstreaming" care, with each team member functioning at the top of his or her license, and sharing accountability for outcomes and resources utilized per patient. Under this system, a well-trained orthopaedic advanced practice provider should be at the front line in managing musculoskeletal disease, appropriately triaging patients to other members of the team based on clinical need and expertise. The orthopaedic surgeon can therefore maximize time spent with patients who are appropriate surgical candidates and provide backup to the team for complex patients. In addition to delivering better value to patients, downstreaming care can create a more rewarding work environment for providers. To achieve truly high-value care, patients must be engaged as active participants in their health. Higher preoperative patient activation—a measure of a patient's propensity to engage in adaptive health behaviors—has been shown to be associated with better pain relief, mental health scores, and satisfaction after total joint replacement. Patients should also be encouraged to articulate their values and preferences during a shared decision-making process in which the surgeon contributes his or her clinical expertise, and the patient and the provider together arrive at the most "appropriate" treatment decision with the greatest value for that patient. To ensure that musculoskeletal providers are appropriately incentivized and rewarded for delivering high-value care, policymakers, payers, and employers must modify payment models. Fee-for-service systems incentivize overutilization and unnecessary care, whereas capitated payment models have been criticized for rewarding undertreatment. Value-based payment models, such as condition-based bundled payments, incentivize the right care for the right patient at the right time by discouraging non-value-added care. Examples of non-value-added care include unnecessary care, inappropriate variations in care and pricing, and avoidable readmissions and complications. Bundled payment programs in orthopaedics, including the CMS Comprehensive Care for Joint Replacement (CJR) model, are commendable steps toward value-based payment. However, such procedure-focused models do not address whether surgery was the appropriate treatment in the first place, missing larger opportunities to reduce the number of inappropriate procedures or to address patients' psychosocial needs (e.g., behavioral health) before proceeding with elective surgery. Multidisciplinary care teams should use evidence-based care pathways and establish appropriateness criteria for diagnostic and therapeutic interventions to ensure that the appropriate treatment is given to the right patient at the right time in order to maximize value. Clinical Leadership Is Key Orthopaedic surgeons must lead care redesign efforts and champion meaningful cultural change around outcomes measurement, data transparency, treatment appropriateness, and team-based care. In these situations, the surgeon champion must communicate a clear and compelling vision that resonates with other stakeholders, and then work closely with the other stakeholders to act on that vision. The physician champion (and orthopaedic surgeons in particular) must also demonstrate a willingness to work in a more collaborative way with other providers in order to optimize value. In doing so, the care team will adopt important working norms such as clinical outcome and cost transparency, greater integration across the continuum of care, and a willingness to experiment with new delivery models and payment methodologies. Clinician leaders must maintain focus on achieving sustainable, patient-centered value with every strategic decision that they make. Conclusions To succeed in value-based care and payment models, orthopaedic surgeons, hospitals, and other stakeholders must rethink all aspects of care delivery. This transformation will involve reorganizing care delivery and incentives around patient-centered value, and embedding these principles into the culture via strong physician leadership. Value-based approaches require an up-front investment of resources, but they will ultimately lead to greater value for patients as well as greater satisfaction and rewards for providers.