769 C OPYRIGHT Ó 2015
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T HE J OURNAL
OF
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AND J OINT
S URGERY, I NCORPORATED
AOA Critical Issues Improving Value in Musculoskeletal Care Delivery AOA Critical Issues David H. Wei, MD, MS, Gillian A. Hawker, MD, MSc, David S. Jevsevar, MD, MBA, and Kevin J. Bozic, MD, MBA
Improving value in musculoskeletal health care has emerged as an important objective in both the United States and Canada. In order to achieve this objective, providers need to have a clear definition of value and an infrastructure for measuring outcomes of interest to patients and costs over the episode of care. Although national patient registries have been established in the United States and Canada, they nevertheless lag behind other registries worldwide in terms of collecting patient-reported outcomes and capturing data from a wide cross-section of hospitals and physicians. With the help of professional medical societies and the creation of national initiatives, patient-reported outcomes data collection on a large scale may be possible, but many challenges remain regarding implementation. Alternatives to the fee-for-service payment model, including pay-for-reporting and pay-for-performance, may help incentivize physicians and health-care providers to obtain and improve on patient-reported outcomes data collection. Other payment reforms, such as bundled payments, have been piloted in certain regions, but their sustainability and long-term success are unclear at this time. Novel health-care delivery strategies aimed at improving quality, coordinating multispecialty care, and enhancing patient participation in shared decision-making have shown promise in improving patient-centered outcomes, but delivery models continue to vary greatly throughout the United States and Canada. The current status of musculoskeletal health-care delivery requires substantial change before the goal of improving patient outcomes and lowering health-care costs can be achieved. Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.
Principles of Value-Based Health Care To curb the unrelenting rise of health-care costs, recent efforts have shifted toward the importance of value in health care in
both the United States and Canada, with value defined as patient outcomes achieved per dollar spent1. The emphasis on achieving higher value for patients, rather than strictly reducing costs, is a
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
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fundamental change in health-care reform. This shift in focus has driven several changes in orthopaedic surgery in both the United States and Canada. We discuss the principles behind the creation of a high-value health-care system, cite examples of how these value-based principles have been applied within orthopaedic surgery, and examine basic differences in payment and delivery systems between the United States and Canada. Value in health care can be defined as health outcomes achieved per dollar spent over the episode of care for a specific health condition1. With the value-based use of the term outcome, we refer to disease-specific, long-term measurements that cover specific interventions (e.g., surgery) and the full cycle of care, including hospitalization, complications, rehabilitation, and recurrences. This definition integrates factors such as a patient’s satisfaction with his or her health, discomfort, and timeliness of treatment, and needs to be risk-adjusted based on the patient’s baseline health and socioeconomic status. The use of the term quality in health care can be confusing; the term has been used to refer to different concepts, sometimes interchangeably with health outcomes. For instance, quality may refer to the use of evidence-based clinical practice guidelines in patient care. However, the value-based use of the term quality refers strictly to patient-centered health outcomes and does not include measures of processes or patients’ satisfaction with services that do not directly impact their health. The use of electronic medical records and the establishment of easily accessible outcomes databases are central to the measurement and analysis of health outcomes. The introduction of nationally representative patient outcome registries is one method of implementing infrastructure for the collection of outcomes, and it has had a meaningful impact in several countries1. For example, providers’ use of data within the Swedish Total Hip Arthroplasty Register has been associated with a threefold decline in the most serious complications2-4. Recent studies of arthroplasty registries worldwide have revealed three international registries that collect patient-reported outcome measures (PROMs): the Swedish Total Hip Arthroplasty Register, the National Joint Registry for England, Wales and Northern Ireland, and the New Zealand Joint Registry5,6. The inclusion of PROMs has aided in the comparison of outcomes from different surgical approaches, the analysis of positive predictors of clinical outcome, and the study of comorbid conditions7-10. The denominator of the value equation is cost, and like outcomes, costs should be centered on the patient and include the full cycle of care11. However, current measures of cost frequently fall short of capturing the costs associated with managing an entire episode of care. Often, cost is equated with charges billed, rather than actual resources consumed during the delivery of care. Furthermore, cost estimates often only include the management of acute illness, ignoring other components of care that may contribute substantially, such as rehabilitation. Cost should be an aggregation of inpatient, outpatient, rehabilitation, drug, physician services, equipment, and facility costs, as well as costs to society from the loss of productivity and time off from work, including any related time off from work that spouses or family members must take.
Lastly, orthopaedic surgery is inundated by new health-care technologies, including implants and devices, as well as drugs and alternative therapies. However, their adoption often precedes the establishment of clinical superiority, or even noninferiority, and occurs without regard to cost. Rigorous clinical trials remain the most important method of evaluating these new technologies and treatments, and national registries with complete patient health outcomes may facilitate our understanding, especially when randomized clinical trials cannot be conducted12. Value-Based Advancements in the United States As medical information becomes more easily obtainable, patients are increasingly demanding a more active role in their care, and many physicians, including orthopaedic surgeons, have shifted toward shared decision-making. Compared with older, paternalistic models involving unilateral decisions made by the treating physicians, shared decision-making allows both the physician and the patient to actively contribute to the medical decisions in orthopaedic surgery. Physicians help educate the patient, and patients relate preferences based on their own values. Incorporating patient preferences can lead to better patient satisfaction, improved decision quality, appropriate utilization of health-care resources by an informed patient, and better outcomes, thereby increasing value for patients13-15. In recent years, several groups in the United States have followed other countries3,16 in improving outcomes through the establishment of clinical registries (Table I). As these registries continue to expand and collect data for future analysis, some have already demonstrated how clinical registries can influence and improve health-care value and patient safety. For example, the authors of one study used a community-based registry of anterior cruciate ligament (ACL) reconstructions in California, with data on more than 16,000 ACL surgical procedures, to analyze the comparative safety of various ACL grafts and to identify risk factors for complications and failure17. Using these data, they developed a tool that calculates risk on the basis of age, sex, race, body mass index, and graft type for surgeons to use during the preoperative patient visit. At the University of Washington and Harborview Medical Center, the Spine End Result Registry led to a validated model for predicting surgical site infections after spine surgery18. The authors were able to counsel patients regarding their individualized surgical risk based on the patient’s comorbidity profile and the invasiveness of surgery. In an organized effort to improve value through evidence, the American Academy of Orthopaedic Surgeons (AAOS) has created evidence-based practice tools (clinical practice guidelines and appropriate use criteria) and has launched a new initiative for the development of performance measures. Clinical practice guidelines, the result of an exhaustive review of the literature, are designed to outline the best practices for the management of a specific condition. Appropriate use criteria were developed to help determine the appropriateness of performing a procedure for a given condition based on the relative risks and benefits derived from the best available scientific evidence and the opinions and experience of clinical experts. Finally, the aim of the performance measures initiative is to create selective, focused,
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TABLE I U.S. Regional and National Orthopaedic Registries Currently Collecting Data Registry Name
Description 42
California Joint Replacement Registry (CJRR)
The CJRR is a voluntary, statewide database started in 2009 for joint arthroplasty patient data. It aims to capture preoperative characteristics, prosthetic device information, and patient outcomes, including pain and function
Michigan Arthroplasty Registry Collaborative Quality Initiative 43 (MARCQI)
The MARCQI is a collaborative quality initiative by Blue Cross Blue Shield of Michigan and Blue Care Network, begun in 2011. As of 2014, the registry had collected data from 44 hospitals for more than 51,000 cases
Kaiser Permanente National Total Joint Replacement Registry 44 (TJRR)
The Kaiser Permanente TJRR was founded in 2001 and began collection in multiple regions of the United States, including California, Hawaii, Washington, Oregon, and Colorado. The results of its data collection include the identification of a hip implant requiring recall, a 10% reduction in revision total knee replacement rates, and reduced volume of minimally invasive procedures leading to improved reduction of pain and better subjective patient outcomes
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American Joint Replacement Registry (AJRR)
The AJRR began as a joint effort by the American Academy of Orthopaedic Surgeons, the American Association of Hip and Knee Surgeons, the Hip Society, and the Knee Society as well as various patient advocacy groups, health insurers, and device manufacturers. Currently, the AJRR receives data from approximately 1800 orthopaedic surgeons who have performed more than 100,000 procedures across 170 hospitals in 48 states
Function and Outcomes Research for Comparative Effectiveness 46 in Total Joint Replacement (FORCE-TJR)
In 2010, the Agency for Healthcare Research and Quality funded the FORCE-TJR, a 4-year research initiative to establish a national network of total joint surgeons. By organizing and collecting data from over 130 orthopaedic surgeons across the United States, the research consortium aims to assess longitudinal outcomes representative of all regions of the country, in order to guide surgical practice and optimize patient function and clinical outcomes
measurable, and actionable tools for quality measurement based on entities proven to contribute to patient outcomes. These performance measures may then contribute to value-based payment strategies and public reporting. Together, these tools add to the armamentarium of strategies for enhancing the value of orthopaedic care. Value-Based Advancements in Canada Canada, in the universal struggle to contain health-care costs and optimize value, is the current leader in three major areas of national infrastructure: health-care standards, legal and consent framework, and patient and public engagement19. The following are some examples of how a few of Canada’s current advancements have increased value for patients. In response to evidence showing high clinical effectiveness but unacceptably long wait times for hip and knee arthroplasty, provincial wait-time strategies were implemented. Wait-time guarantees were established, with mandatory provincial reporting on the achievement of these benchmarks. Access to arthroplasty surgery was increased through enhanced hospital funding earmarked for total joint arthroplasty and the implementation of central intake clinics to expedite access, triage, and the assessment of potential surgical candidates. Key elements of these clinics were the use of a standardized referral form; central intake; patient choice, e.g., of a specific surgeon or the first available appoint-
ment; expanded roles for physiotherapists and other health professionals in preoperative assessment and postoperative review of patients, with orthopaedic surgical consultation as required; the use of standardized patient assessment tools; and the use of standardized clinical pathways for the management of surgical and nonsurgical patients. In contrast to clinical practice guidelines, clinical pathways are used by multidisciplinary teams during every stage of treatment from the time of referral to presurgical visits, surgery, inpatient stay, and postsurgical management and rehabilitation. In Alberta, the Alberta Orthopaedic Society and the Alberta Bone and Joint Health Institute evaluated their new clinical pathway compared with usual care in a randomized clinical trial20. They showed that, in addition to having shorter surgical wait times, patients treated according to the new clinical pathway experienced significantly greater improvements in pain and function than those who received usual care. Despite the documented improved efficiencies and patient outcomes, not all surgeons have been willing to participate in centralized triage programs. Barriers to participation include concerns about autonomy of practice; maintaining a sufficient surgical load if patients are triaged to the “next available” or their preferred surgeon; and trust in other health professionals, including physical therapists or family physicians, to capably conduct the initial assessment and triage of patients for surgical consultation. The Canadian Joint Replacement Registry (CJRR) was
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formed through a collaboration between the Canadian Orthopaedic Association and the Canadian Institute for Health Information in 2001 to provide patient and procedure-related information beyond that available in provincial administrative databases21. Initially, data capture was a challenge; participation was voluntary and data regarding less than half of the total knee and hip arthroplasties were submitted. Barriers to participation in the registry included surgeons’ concerns about the ramifications of disclosure of their surgical outcomes; lack of trust in the current methods used to adjust for case complexity, particularly among surgeons at tertiary centers; and the time required to complete the necessary datacollection forms. Additionally, there were concerns that not all patients within a participating practice were being included in the registry, potentially biasing the information received. In order to improve the external validity and, thus, usefulness of the CJRR, participation is now mandated in several provinces. The CJRR contains demographic, clinical, and prosthesis data from all but one province. Individual provinces and hospitals may include additional information, such as PROMs, in their provincial or hospital registries. Reports are publicly available and have been helpful in highlighting variability among the Canadian provinces in terms of patient demographics and implant selection, while also enabling a comparison with international arthroplasty rates. An analysis of factors contributing to variability may help to elucidate the effects of direct-to-consumer advertising or obesity on patient outcomes. Delivery and Payment Models United States The current payment system for the majority of health care delivered in the United States is fee-for-service (FFS). Under this system, providers are paid based on the volume and intensity of services they provide. Ample evidence has shown that FFS payment systems have contributed to the uncontrollable rise in health-care costs in the United States22-24. These problems include overuse of services (utilization); a disregard of provider performance, quality, or efficiency; and inappropriate focus on volume rather than value. Moreover, the FFS payment system does not align financial incentives among different providers. Several alternative strategies to the current FFS payment system have been piloted in the United States. One strategy has been the introduction of payment models that are episode-based, termed bundled payments. Under this payment system, a single lump-sum payment is given to all providers, including hospitals, physicians, and other providers, for an acute care episode such as total knee arthroplasty. Surgical episodes of care include preoperative, surgical, and postoperative care delivered in both inpatient and outpatient settings25,26. Potential benefits include incentives for more coordinated patient care, improved outcomes, and lower costs or reduced variation in costs, as well as greater transparency and accountability. The Geisinger Health System in Pennsylvania piloted global bundled payments for total joint arthroplasty, and demonstrated decreased hospital costs, shorter lengths of stay, lower readmission rates, and improved outcomes through decreased complication rates27,28. Another novel payment strategy involves reforming healthcare delivery through the creation of a patient-centered medical
home. This model combines four components based on primary care medicine. The first is creating access to high-quality, coordinated, and comprehensive care with sustained personal relationships. This is meant to decrease uncoordinated relationships with various specialists. The second is employing the chronic care model for managing chronic disease states such as osteoarthritis. The third is a patient-centered focus that promotes patient engagement, which allows patients to have input in their care. Finally, the fourth component is the implementation of electronic health records to help facilitate evidence-based care in a seamless fashion. To accomplish these goals, initiatives often include building learning collaboratives among multiple practices, utilizing transformation coaches and practice consultants, and reforming payment to support advanced primary care services29. Blue Cross Blue Shield of Michigan began implementing the medical home system in 2005 and, as of July 2012, reported saving over $150 million in health-care expenditures not only for primary care doctors but for specialists, too25. A third strategy for payment reform is the formation of accountable care organizations (ACOs), or groups of health-care providers who agree to share responsibility for coordinating lower-risk and higher-quality care for a defined population of patients. Originally created by the Affordable Care Act, there are several essential structural components to establishing an ACO25. First, all providers share accountability for patient health outcomes, not just health-care costs. Second, an ACO builds from the same themes of the medical home model, encouraging coordination among primary care physicians, hospitals, and specialists. Third, the payment model of an ACO involves using benchmarks to measure savings, which are shared with all providers. Fourth, an ACO is required to have a system in place to measure and report performance and quality. Several examples of ACOs exist today that show progress toward improving value. These include Atrius Health and Beth Israel Deaconess Physician Organization in Massachusetts and the Iowa Health System28. Canada The Canadian government is a parliamentary democracy and federal state, in which power is distributed between the national government, ten provinces, and three territories. While the federal government is responsible for some aspects of health and health care, the provinces and territories bear the bulk of the responsibility for financing and delivering health services. The Canadian government initially introduced its version of Medicare by passing the Medical Care Act and the Diagnostic Services Act to establish the basis for a universal, publicly financed health insurance system. This fee-for-service system was eventually replaced by the Canada Health Act, which set national standards for hospital, diagnostic, and medical care services30. The act mandated the following for provincial health insurance programs in order to receive federal funding: universality, portability among provinces, public administration, accessibility, and comprehensiveness31. Physicians were given clinical autonomy and control over the location and organization of their practice. Although the U.S. and Canadian health-care systems have notable differences, their efforts in health-care reform are more similar than they are
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different. These similarities are seen in the Canadian themes of reform that overlap with the Institute of Medicine’s goals, including better access, integration of care, team-based approaches, improved quality, and the implementation of electronic medical records. Just as the states are given independence in the implementation of reforms passed by the Affordable Care Act, so are the Canadian provinces allowed to design and implement their reforms. As may be expected, the improvements and initiatives in the United States and Canada have influenced each other. One focus of reform in many Canadian provinces has been the development of multidisciplinary, interprofessional healthcare teams, similar to the medical homes in the United States32. These teams are meant to improve access to care, provide continuity and coordination among services, and increase the quality of care. Increasingly, Canadian provinces are engaging in payment reforms, moving toward fee-for-service with capitation or incentive payment models; however, the implementation of payment reform remains highly variable. Future Directions Federal/Provincial Agencies Several Canadian provincial governments now fund agencies to support the research and development of value-based processes. For example, Health Quality Ontario is an independent government agency that seeks to monitor and help attain quality benchmarks. In addition, in Ontario there is an increasing emphasis on bundled funding for procedures. The list of procedures being transitioned to this payment model, termed the Health-Based Allocation Model, continues to expand. Patient Activation The importance of active engagement of patients in their own care is an emerging concept that has gained supportive evidence in the literature in recent years33. The term patient activation refers to patients’ ability to take independent and knowledgeable, skillful action to manage their health and care. Studies have demonstrated better health outcomes, better experiences, and lower health-care costs when patients are more engaged34. As health-care delivery systems evolve, ensuring patient activation will be critical to improving value. Improving Value in Your Practice Musculoskeletal care providers face multiple challenges to improving the value of care that they provide, beginning with measuring patient-centered outcomes and episode-of-care costs at a granular level. These measurements may be utilized to optimize outcomes and reduce costs by identifying and eliminating non-value-added steps in care delivery through the use of lean methodology35,36. National initiatives, such as the Patient-Centered Outcomes Research Institute (PCORI), will be important in facilitating the development of systems and methods to improve data collection on a large scale37. Professional medical societies can also serve a role in developing and coordinating patient-centered outcomes collection, but participation from individual clinicians remains the foundation of clinical registries. The clinical benefits
of registries are only beginning to be fully realized in the United States and Canada, but their contributions have already generated important changes in the delivery and improvement of patient health care and safety. The measurement of episode-of-care costs is a challenging but key component in the process of improving value in clinical practice. In recent years, health-care organizations have employed sophisticated techniques such as activity-based costing (ABC) to better understand their costs on a granular level38,39. However, this technique has had limited adoption because its methodology relies heavily on burdensome repeated interviews and surveys of employees40. In a modification of this technique, a newer approach called time-driven ABC (TDABC) has simplified the process41. TDABC has been successfully used to measure costs in service organizations as well as health-care organizations, including hospitals and outpatient medical clinics40. Through granular measurements of patient outcomes from clinical registries and costs derived from TDABC, physicians in practice will be poised to optimize both the numerator and denominator of the value equation. Conclusion While the importance of increasing value in health care is clear, the current status of health care in the United States and Canada requires substantial change before the goal of improving patient outcomes and lowering health-care costs can be achieved. Payment reforms such as bundled payments have been piloted, but their sustainability or success in terms of improving value have yet to be proven25. A shift from the fee-for-service model to payfor-reporting or pay-for-performance may prove to be useful for incentivizing physicians and health-care providers to obtain and improve patient-centered outcomes, but additional challenges of implementation remain, such as insuring against unexpected loss and avoiding incentives to “skimp” on care. n
David H. Wei, MD, MS Department of Orthopaedics, Tufts University Medical Center, 800 Washington Street, TMC Box #306, Boston, MA 02111. E-mail address: [email protected] Gillian A. Hawker, MD, MSc Women’s College Research Institute, Women’s College Hospital, University of Toronto, 190 Elizabeth Street, Suite RFE 3-805, Toronto, ON M5G 2C4, Canada. E-mail address: [email protected] David S. Jevsevar, MD, MBA Intermountain Healthcare, 652 South Medical Center Drive, Suite 400, St. George, UT 84770. E-mail address: [email protected]
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Kevin J. Bozic, MD, MBA Department of Orthopaedic Surgery, University of California,
San Francisco, 500 Parnassus Avenue, MUW320, San Francisco, CA 94143-0728. E-mail address: [email protected]
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23. Schroeder SA, Frist W; National Commission on Physician Payment Reform. Phasing out fee-for-service payment. N Engl J Med. 2013 May 23;368(21):2029-32. Epub 2013 Mar 27. 24. Orszag PR, Ellis P. The challenge of rising health care costs—a view from the Congressional Budget Office. N Engl J Med. 2007 Nov 1;357(18):1793-5. 25. McIntyre LF. Exploring new practice models delivering orthopedic care: can we significantly decrease delivery costs and improve quality? Sports Med Arthrosc. 2013 Sep;21(3):152-4. 26. Froimson MI, Rana A, White RE Jr, Marshall A, Schutzer SF, Healy WL, Naas P, Daubert G, Iorio R, Parsley B. Bundled payments for care improvement initiative: the next evolution of payment formulations: AAHKS Bundled Payment Task Force. J Arthroplasty. 2013 Sep;28(8)(Suppl):157-65. 27. Casale AS, Paulus RA, Selna MJ, Doll MC, Bothe AE Jr, McKinley KE, Berry SA, Davis DE, Gilfillan RJ, Hamory BH, Steele GD Jr. “ProvenCareSM”: a provider-driven pay-for-performance program for acute episodic cardiac surgical care. Ann Surg. 2007 Oct;246(4):613-21; discussion 621-3. 28. Calsyn M, Lee EO. Alternatives to fee-for-service payments in health care: moving from volume to value. Center for American Progress. 2012. http://cdn. americanprogress.org/wp-content/uploads/2012/09/FeeforService4.pdf. Accessed 2015 Jan 8. 29. Edwards ST, Bitton A, Hong J, Landon BE. Patient-centered medical home initiatives expanded in 2009-13: providers, patients, and payment incentives increased. Health Aff (Millwood). 2014 Oct;33(10):1823-31. 30. Marchildon GP. Canada: health system review. Health Systems in Transition. 2013;15(1):1-179. European Observatory on Health Systems and Policies. 2013. http://www.euro.who.int/__data/assets/pdf_file/0011/181955/e96759.pdf. Accessed 2015 Jan 1. 31. Hutchison B, Levesque JF, Strumpf E, Coyle N. Primary health care in Canada: systems in motion. Milbank Q. 2011 Jun;89(2):256-88. 32. Strumpf E, Levesque JF, Coyle N, Hutchison B, Barnes M, Wedel RJ. Innovative and diverse strategies toward primary health care reform: lessons learned from the Canadian experience. J Am Board Fam Med. 2012 Mar;25(Suppl 1):S27-33. 33. Hibbard JH, Greene J. What the evidence shows about patient activation: better health outcomes and care experiences; fewer data on costs. Health Aff (Millwood). 2013 Feb;32(2):207-14. 34. Hibbard JH, Greene J, Overton V. Patients with lower activation associated with higher costs; delivery systems should know their patients’ ‘scores’. Health Aff (Millwood). 2013 Feb;32(2):216-22. 35. Collar RM, Shuman AG, Feiner S, McGonegal AK, Heidel N, Duck M, McLean SA, Billi JE, Healy DW, Bradford CR. Lean management in academic surgery. J Am Coll Surg. 2012 Jun;214(6):928-36. 36. Lunardini D, Arington R, Canacari EG, Gamboa K, Wagner K, McGuire KJ. Lean principles to optimize instrument utilization for spine surgery in an academic medical center: an opportunity to standardize, cut costs, and build a culture of improvement. Spine (Phila Pa 1976). 2014 Sep 15;39(20):1714-7. 37. Brinker MR, O’Connor DP. Stakeholders in outcome measures: review from a clinical perspective. Clin Orthop Relat Res. 2013 Nov;471(11):3426-36. 38. Lievens Y, van den Bogaert W, Kesteloot K. Activity-based costing: a practical model for cost calculation in radiotherapy. Int J Radiat Oncol Biol Phys. 2003 Oct 1; 57(2):522-35. 39. Ross TK. Analyzing health care operations using ABC. J Health Care Finance. 2004 Spring;30(3):1-20. 40. Demeere N, Stouthuysen K, Roodhooft F. Time-driven activity-based costing in an outpatient clinic environment: development, relevance and managerial impact. Health Policy. 2009 Oct;92(2-3):296-304. Epub 2009 Jun 7. 41. Kaplan RS, Anderson SR. Time-driven activity-based costing. Harv Bus Rev. 2004 Nov;82(11):131-40. 42. Lansky D, Nwachukwu BU, Bozic KJ. Using financial incentives to improve value in orthopaedics. Clin Orthop Relat Res. 2012 Apr;470(4):1027-37. 43. Hallstrom B, Hughes RE, Cowen ME, Singal B, Igrisan R. MARCQI: Michigan Arthroplasty Registry Collaborative Quality Initiative. http://marcqi.org/index.html. Accessed 2014 Dec 6. 44. Paxton EW, Inacio M, Slipchenko T, Fithian DC. The Kaiser Permanente national total joint replacement registry. Perm J. 2008 Summer;12(3):12-6. 45. Smith MA, Smith WT. The American Joint Replacement Registry. Orthop Nurs. 2012 Sep-Oct;31(5):296-9; quiz 300-1. 46. Franklin PD, Allison JJ, Ayers DC. Beyond joint implant registries: a patientcentered research consortium for comparative effectiveness in total joint replacement. JAMA. 2012 Sep 26;308(12):1217-8.
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BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
AOA Critical Issues Improving Value in Musculoskeletal Care Delivery AOA Critical Issues David H. Wei, MD, MS, Gillian A. Hawker, MD, MSc, David S. Jevsevar, MD, MBA, and Kevin J. Bozic, MD, MBA
Improving value in musculoskeletal health care has emerged as an important objective in both the United States and Canada. In order to achieve this objective, providers need to have a clear definition of value and an infrastructure for measuring outcomes of interest to patients and costs over the episode of care. Although national patient registries have been established in the United States and Canada, they nevertheless lag behind other registries worldwide in terms of collecting patient-reported outcomes and capturing data from a wide cross-section of hospitals and physicians. With the help of professional medical societies and the creation of national initiatives, patient-reported outcomes data collection on a large scale may be possible, but many challenges remain regarding implementation. Alternatives to the fee-for-service payment model, including pay-for-reporting and pay-for-performance, may help incentivize physicians and health-care providers to obtain and improve on patient-reported outcomes data collection. Other payment reforms, such as bundled payments, have been piloted in certain regions, but their sustainability and long-term success are unclear at this time. Novel health-care delivery strategies aimed at improving quality, coordinating multispecialty care, and enhancing patient participation in shared decision-making have shown promise in improving patient-centered outcomes, but delivery models continue to vary greatly throughout the United States and Canada. The current status of musculoskeletal health-care delivery requires substantial change before the goal of improving patient outcomes and lowering health-care costs can be achieved. Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.
Principles of Value-Based Health Care To curb the unrelenting rise of health-care costs, recent efforts have shifted toward the importance of value in health care in
both the United States and Canada, with value defined as patient outcomes achieved per dollar spent1. The emphasis on achieving higher value for patients, rather than strictly reducing costs, is a
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
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fundamental change in health-care reform. This shift in focus has driven several changes in orthopaedic surgery in both the United States and Canada. We discuss the principles behind the creation of a high-value health-care system, cite examples of how these value-based principles have been applied within orthopaedic surgery, and examine basic differences in payment and delivery systems between the United States and Canada. Value in health care can be defined as health outcomes achieved per dollar spent over the episode of care for a specific health condition1. With the value-based use of the term outcome, we refer to disease-specific, long-term measurements that cover specific interventions (e.g., surgery) and the full cycle of care, including hospitalization, complications, rehabilitation, and recurrences. This definition integrates factors such as a patient’s satisfaction with his or her health, discomfort, and timeliness of treatment, and needs to be risk-adjusted based on the patient’s baseline health and socioeconomic status. The use of the term quality in health care can be confusing; the term has been used to refer to different concepts, sometimes interchangeably with health outcomes. For instance, quality may refer to the use of evidence-based clinical practice guidelines in patient care. However, the value-based use of the term quality refers strictly to patient-centered health outcomes and does not include measures of processes or patients’ satisfaction with services that do not directly impact their health. The use of electronic medical records and the establishment of easily accessible outcomes databases are central to the measurement and analysis of health outcomes. The introduction of nationally representative patient outcome registries is one method of implementing infrastructure for the collection of outcomes, and it has had a meaningful impact in several countries1. For example, providers’ use of data within the Swedish Total Hip Arthroplasty Register has been associated with a threefold decline in the most serious complications2-4. Recent studies of arthroplasty registries worldwide have revealed three international registries that collect patient-reported outcome measures (PROMs): the Swedish Total Hip Arthroplasty Register, the National Joint Registry for England, Wales and Northern Ireland, and the New Zealand Joint Registry5,6. The inclusion of PROMs has aided in the comparison of outcomes from different surgical approaches, the analysis of positive predictors of clinical outcome, and the study of comorbid conditions7-10. The denominator of the value equation is cost, and like outcomes, costs should be centered on the patient and include the full cycle of care11. However, current measures of cost frequently fall short of capturing the costs associated with managing an entire episode of care. Often, cost is equated with charges billed, rather than actual resources consumed during the delivery of care. Furthermore, cost estimates often only include the management of acute illness, ignoring other components of care that may contribute substantially, such as rehabilitation. Cost should be an aggregation of inpatient, outpatient, rehabilitation, drug, physician services, equipment, and facility costs, as well as costs to society from the loss of productivity and time off from work, including any related time off from work that spouses or family members must take.
Lastly, orthopaedic surgery is inundated by new health-care technologies, including implants and devices, as well as drugs and alternative therapies. However, their adoption often precedes the establishment of clinical superiority, or even noninferiority, and occurs without regard to cost. Rigorous clinical trials remain the most important method of evaluating these new technologies and treatments, and national registries with complete patient health outcomes may facilitate our understanding, especially when randomized clinical trials cannot be conducted12. Value-Based Advancements in the United States As medical information becomes more easily obtainable, patients are increasingly demanding a more active role in their care, and many physicians, including orthopaedic surgeons, have shifted toward shared decision-making. Compared with older, paternalistic models involving unilateral decisions made by the treating physicians, shared decision-making allows both the physician and the patient to actively contribute to the medical decisions in orthopaedic surgery. Physicians help educate the patient, and patients relate preferences based on their own values. Incorporating patient preferences can lead to better patient satisfaction, improved decision quality, appropriate utilization of health-care resources by an informed patient, and better outcomes, thereby increasing value for patients13-15. In recent years, several groups in the United States have followed other countries3,16 in improving outcomes through the establishment of clinical registries (Table I). As these registries continue to expand and collect data for future analysis, some have already demonstrated how clinical registries can influence and improve health-care value and patient safety. For example, the authors of one study used a community-based registry of anterior cruciate ligament (ACL) reconstructions in California, with data on more than 16,000 ACL surgical procedures, to analyze the comparative safety of various ACL grafts and to identify risk factors for complications and failure17. Using these data, they developed a tool that calculates risk on the basis of age, sex, race, body mass index, and graft type for surgeons to use during the preoperative patient visit. At the University of Washington and Harborview Medical Center, the Spine End Result Registry led to a validated model for predicting surgical site infections after spine surgery18. The authors were able to counsel patients regarding their individualized surgical risk based on the patient’s comorbidity profile and the invasiveness of surgery. In an organized effort to improve value through evidence, the American Academy of Orthopaedic Surgeons (AAOS) has created evidence-based practice tools (clinical practice guidelines and appropriate use criteria) and has launched a new initiative for the development of performance measures. Clinical practice guidelines, the result of an exhaustive review of the literature, are designed to outline the best practices for the management of a specific condition. Appropriate use criteria were developed to help determine the appropriateness of performing a procedure for a given condition based on the relative risks and benefits derived from the best available scientific evidence and the opinions and experience of clinical experts. Finally, the aim of the performance measures initiative is to create selective, focused,
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TABLE I U.S. Regional and National Orthopaedic Registries Currently Collecting Data Registry Name
Description 42
California Joint Replacement Registry (CJRR)
The CJRR is a voluntary, statewide database started in 2009 for joint arthroplasty patient data. It aims to capture preoperative characteristics, prosthetic device information, and patient outcomes, including pain and function
Michigan Arthroplasty Registry Collaborative Quality Initiative 43 (MARCQI)
The MARCQI is a collaborative quality initiative by Blue Cross Blue Shield of Michigan and Blue Care Network, begun in 2011. As of 2014, the registry had collected data from 44 hospitals for more than 51,000 cases
Kaiser Permanente National Total Joint Replacement Registry 44 (TJRR)
The Kaiser Permanente TJRR was founded in 2001 and began collection in multiple regions of the United States, including California, Hawaii, Washington, Oregon, and Colorado. The results of its data collection include the identification of a hip implant requiring recall, a 10% reduction in revision total knee replacement rates, and reduced volume of minimally invasive procedures leading to improved reduction of pain and better subjective patient outcomes
45
American Joint Replacement Registry (AJRR)
The AJRR began as a joint effort by the American Academy of Orthopaedic Surgeons, the American Association of Hip and Knee Surgeons, the Hip Society, and the Knee Society as well as various patient advocacy groups, health insurers, and device manufacturers. Currently, the AJRR receives data from approximately 1800 orthopaedic surgeons who have performed more than 100,000 procedures across 170 hospitals in 48 states
Function and Outcomes Research for Comparative Effectiveness 46 in Total Joint Replacement (FORCE-TJR)
In 2010, the Agency for Healthcare Research and Quality funded the FORCE-TJR, a 4-year research initiative to establish a national network of total joint surgeons. By organizing and collecting data from over 130 orthopaedic surgeons across the United States, the research consortium aims to assess longitudinal outcomes representative of all regions of the country, in order to guide surgical practice and optimize patient function and clinical outcomes
measurable, and actionable tools for quality measurement based on entities proven to contribute to patient outcomes. These performance measures may then contribute to value-based payment strategies and public reporting. Together, these tools add to the armamentarium of strategies for enhancing the value of orthopaedic care. Value-Based Advancements in Canada Canada, in the universal struggle to contain health-care costs and optimize value, is the current leader in three major areas of national infrastructure: health-care standards, legal and consent framework, and patient and public engagement19. The following are some examples of how a few of Canada’s current advancements have increased value for patients. In response to evidence showing high clinical effectiveness but unacceptably long wait times for hip and knee arthroplasty, provincial wait-time strategies were implemented. Wait-time guarantees were established, with mandatory provincial reporting on the achievement of these benchmarks. Access to arthroplasty surgery was increased through enhanced hospital funding earmarked for total joint arthroplasty and the implementation of central intake clinics to expedite access, triage, and the assessment of potential surgical candidates. Key elements of these clinics were the use of a standardized referral form; central intake; patient choice, e.g., of a specific surgeon or the first available appoint-
ment; expanded roles for physiotherapists and other health professionals in preoperative assessment and postoperative review of patients, with orthopaedic surgical consultation as required; the use of standardized patient assessment tools; and the use of standardized clinical pathways for the management of surgical and nonsurgical patients. In contrast to clinical practice guidelines, clinical pathways are used by multidisciplinary teams during every stage of treatment from the time of referral to presurgical visits, surgery, inpatient stay, and postsurgical management and rehabilitation. In Alberta, the Alberta Orthopaedic Society and the Alberta Bone and Joint Health Institute evaluated their new clinical pathway compared with usual care in a randomized clinical trial20. They showed that, in addition to having shorter surgical wait times, patients treated according to the new clinical pathway experienced significantly greater improvements in pain and function than those who received usual care. Despite the documented improved efficiencies and patient outcomes, not all surgeons have been willing to participate in centralized triage programs. Barriers to participation include concerns about autonomy of practice; maintaining a sufficient surgical load if patients are triaged to the “next available” or their preferred surgeon; and trust in other health professionals, including physical therapists or family physicians, to capably conduct the initial assessment and triage of patients for surgical consultation. The Canadian Joint Replacement Registry (CJRR) was
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formed through a collaboration between the Canadian Orthopaedic Association and the Canadian Institute for Health Information in 2001 to provide patient and procedure-related information beyond that available in provincial administrative databases21. Initially, data capture was a challenge; participation was voluntary and data regarding less than half of the total knee and hip arthroplasties were submitted. Barriers to participation in the registry included surgeons’ concerns about the ramifications of disclosure of their surgical outcomes; lack of trust in the current methods used to adjust for case complexity, particularly among surgeons at tertiary centers; and the time required to complete the necessary datacollection forms. Additionally, there were concerns that not all patients within a participating practice were being included in the registry, potentially biasing the information received. In order to improve the external validity and, thus, usefulness of the CJRR, participation is now mandated in several provinces. The CJRR contains demographic, clinical, and prosthesis data from all but one province. Individual provinces and hospitals may include additional information, such as PROMs, in their provincial or hospital registries. Reports are publicly available and have been helpful in highlighting variability among the Canadian provinces in terms of patient demographics and implant selection, while also enabling a comparison with international arthroplasty rates. An analysis of factors contributing to variability may help to elucidate the effects of direct-to-consumer advertising or obesity on patient outcomes. Delivery and Payment Models United States The current payment system for the majority of health care delivered in the United States is fee-for-service (FFS). Under this system, providers are paid based on the volume and intensity of services they provide. Ample evidence has shown that FFS payment systems have contributed to the uncontrollable rise in health-care costs in the United States22-24. These problems include overuse of services (utilization); a disregard of provider performance, quality, or efficiency; and inappropriate focus on volume rather than value. Moreover, the FFS payment system does not align financial incentives among different providers. Several alternative strategies to the current FFS payment system have been piloted in the United States. One strategy has been the introduction of payment models that are episode-based, termed bundled payments. Under this payment system, a single lump-sum payment is given to all providers, including hospitals, physicians, and other providers, for an acute care episode such as total knee arthroplasty. Surgical episodes of care include preoperative, surgical, and postoperative care delivered in both inpatient and outpatient settings25,26. Potential benefits include incentives for more coordinated patient care, improved outcomes, and lower costs or reduced variation in costs, as well as greater transparency and accountability. The Geisinger Health System in Pennsylvania piloted global bundled payments for total joint arthroplasty, and demonstrated decreased hospital costs, shorter lengths of stay, lower readmission rates, and improved outcomes through decreased complication rates27,28. Another novel payment strategy involves reforming healthcare delivery through the creation of a patient-centered medical
home. This model combines four components based on primary care medicine. The first is creating access to high-quality, coordinated, and comprehensive care with sustained personal relationships. This is meant to decrease uncoordinated relationships with various specialists. The second is employing the chronic care model for managing chronic disease states such as osteoarthritis. The third is a patient-centered focus that promotes patient engagement, which allows patients to have input in their care. Finally, the fourth component is the implementation of electronic health records to help facilitate evidence-based care in a seamless fashion. To accomplish these goals, initiatives often include building learning collaboratives among multiple practices, utilizing transformation coaches and practice consultants, and reforming payment to support advanced primary care services29. Blue Cross Blue Shield of Michigan began implementing the medical home system in 2005 and, as of July 2012, reported saving over $150 million in health-care expenditures not only for primary care doctors but for specialists, too25. A third strategy for payment reform is the formation of accountable care organizations (ACOs), or groups of health-care providers who agree to share responsibility for coordinating lower-risk and higher-quality care for a defined population of patients. Originally created by the Affordable Care Act, there are several essential structural components to establishing an ACO25. First, all providers share accountability for patient health outcomes, not just health-care costs. Second, an ACO builds from the same themes of the medical home model, encouraging coordination among primary care physicians, hospitals, and specialists. Third, the payment model of an ACO involves using benchmarks to measure savings, which are shared with all providers. Fourth, an ACO is required to have a system in place to measure and report performance and quality. Several examples of ACOs exist today that show progress toward improving value. These include Atrius Health and Beth Israel Deaconess Physician Organization in Massachusetts and the Iowa Health System28. Canada The Canadian government is a parliamentary democracy and federal state, in which power is distributed between the national government, ten provinces, and three territories. While the federal government is responsible for some aspects of health and health care, the provinces and territories bear the bulk of the responsibility for financing and delivering health services. The Canadian government initially introduced its version of Medicare by passing the Medical Care Act and the Diagnostic Services Act to establish the basis for a universal, publicly financed health insurance system. This fee-for-service system was eventually replaced by the Canada Health Act, which set national standards for hospital, diagnostic, and medical care services30. The act mandated the following for provincial health insurance programs in order to receive federal funding: universality, portability among provinces, public administration, accessibility, and comprehensiveness31. Physicians were given clinical autonomy and control over the location and organization of their practice. Although the U.S. and Canadian health-care systems have notable differences, their efforts in health-care reform are more similar than they are
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different. These similarities are seen in the Canadian themes of reform that overlap with the Institute of Medicine’s goals, including better access, integration of care, team-based approaches, improved quality, and the implementation of electronic medical records. Just as the states are given independence in the implementation of reforms passed by the Affordable Care Act, so are the Canadian provinces allowed to design and implement their reforms. As may be expected, the improvements and initiatives in the United States and Canada have influenced each other. One focus of reform in many Canadian provinces has been the development of multidisciplinary, interprofessional healthcare teams, similar to the medical homes in the United States32. These teams are meant to improve access to care, provide continuity and coordination among services, and increase the quality of care. Increasingly, Canadian provinces are engaging in payment reforms, moving toward fee-for-service with capitation or incentive payment models; however, the implementation of payment reform remains highly variable. Future Directions Federal/Provincial Agencies Several Canadian provincial governments now fund agencies to support the research and development of value-based processes. For example, Health Quality Ontario is an independent government agency that seeks to monitor and help attain quality benchmarks. In addition, in Ontario there is an increasing emphasis on bundled funding for procedures. The list of procedures being transitioned to this payment model, termed the Health-Based Allocation Model, continues to expand. Patient Activation The importance of active engagement of patients in their own care is an emerging concept that has gained supportive evidence in the literature in recent years33. The term patient activation refers to patients’ ability to take independent and knowledgeable, skillful action to manage their health and care. Studies have demonstrated better health outcomes, better experiences, and lower health-care costs when patients are more engaged34. As health-care delivery systems evolve, ensuring patient activation will be critical to improving value. Improving Value in Your Practice Musculoskeletal care providers face multiple challenges to improving the value of care that they provide, beginning with measuring patient-centered outcomes and episode-of-care costs at a granular level. These measurements may be utilized to optimize outcomes and reduce costs by identifying and eliminating non-value-added steps in care delivery through the use of lean methodology35,36. National initiatives, such as the Patient-Centered Outcomes Research Institute (PCORI), will be important in facilitating the development of systems and methods to improve data collection on a large scale37. Professional medical societies can also serve a role in developing and coordinating patient-centered outcomes collection, but participation from individual clinicians remains the foundation of clinical registries. The clinical benefits
of registries are only beginning to be fully realized in the United States and Canada, but their contributions have already generated important changes in the delivery and improvement of patient health care and safety. The measurement of episode-of-care costs is a challenging but key component in the process of improving value in clinical practice. In recent years, health-care organizations have employed sophisticated techniques such as activity-based costing (ABC) to better understand their costs on a granular level38,39. However, this technique has had limited adoption because its methodology relies heavily on burdensome repeated interviews and surveys of employees40. In a modification of this technique, a newer approach called time-driven ABC (TDABC) has simplified the process41. TDABC has been successfully used to measure costs in service organizations as well as health-care organizations, including hospitals and outpatient medical clinics40. Through granular measurements of patient outcomes from clinical registries and costs derived from TDABC, physicians in practice will be poised to optimize both the numerator and denominator of the value equation. Conclusion While the importance of increasing value in health care is clear, the current status of health care in the United States and Canada requires substantial change before the goal of improving patient outcomes and lowering health-care costs can be achieved. Payment reforms such as bundled payments have been piloted, but their sustainability or success in terms of improving value have yet to be proven25. A shift from the fee-for-service model to payfor-reporting or pay-for-performance may prove to be useful for incentivizing physicians and health-care providers to obtain and improve patient-centered outcomes, but additional challenges of implementation remain, such as insuring against unexpected loss and avoiding incentives to “skimp” on care. n
David H. Wei, MD, MS Department of Orthopaedics, Tufts University Medical Center, 800 Washington Street, TMC Box #306, Boston, MA 02111. E-mail address: [email protected] Gillian A. Hawker, MD, MSc Women’s College Research Institute, Women’s College Hospital, University of Toronto, 190 Elizabeth Street, Suite RFE 3-805, Toronto, ON M5G 2C4, Canada. E-mail address: [email protected] David S. Jevsevar, MD, MBA Intermountain Healthcare, 652 South Medical Center Drive, Suite 400, St. George, UT 84770. E-mail address: [email protected]
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Kevin J. Bozic, MD, MBA Department of Orthopaedic Surgery, University of California,
San Francisco, 500 Parnassus Avenue, MUW320, San Francisco, CA 94143-0728. E-mail address: [email protected]
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