Dr. Alex Vaccaro on volume vs. value in spine care

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The U.S. healthcare system continues its push away from a fee-for-service system toward value-based care, but providers and payers can't seem to agree on a universal definition for value-based care.

During Becker's 18th Annual Spine, Orthopedic and Pain Management-Driven ASC + The Future of Spine Conference, Alexander Vaccaro, MD, PhD, spine surgeon and president of Rothman Orthopaedic Institute in Philadelphia, outlined what volume and value-based care might look like for spine providers in the future.

Below is an excerpt from the conversation, slightly edited for clarity. To view the full session on-demand, click here

Note: Responses are lightly edited for style and clarity.

Question: There's been a huge transformation in talking about value from large payers in large systems. How do you view this volume versus value issue?

Dr. Vaccaro: So, let's go back to when we had HMOs and then moved to capitation. Costs are out of control. Let's pay a provider a dollar for an episode of care. So, if you go beyond care paradigms, or care pathways, you're at risk, and therefore you're not going to do it. We did that and it worked for a while. But the big term nowadays is value. If you ask 10 people what value is, they'll give you 10 different definitions. What value means to me is treating the right patient, at the right time, with the right procedure, and moving them on to become more functional.

What does value look like in the future, in a population health? You walk into a spine surgeon's office and you have something that I know will not get better with 25 epidural injections, four months of physical therapy, anti-inflammatory medications, because it's going to result in surgery. So, value care is that person goes to the operating room the next day. They don't go through the nonoperative churn. 

A [patient] comes into my office with chronic back pain, never going to do well with surgery. That person is not going to get 25 injections, narcotics, physical therapy for too much — that person is going to get a prescription and a home therapy program and say, 'Listen, the healthcare system can't change the natural history of what you have.' That's value-based healthcare.

Therefore, when you get to that point, now you do volume. I'm a surgeon. I want to operate every single day on all those people who need surgery, because that's the most cost-effective way of doing it. So, I am busy. I'm being used to the maximum license. These other patients are not going to go through the nonoperative mill and just milk the system for money. They're going to go right into a home therapy program. And we're going to say, 'Listen, we can't help you. You're not going to get on narcotics. We're not going to go down that path. We're not going to stick needles in you.' That's the future. It's volume and value for the right patient, right time with the right procedure.

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