'Risk' replacing 'value': 5 surgeons discuss the future of orthopedic care delivery


After some initial success in bundled payment models, many orthopedic providers are dropping out of such Medicare programs as the continuous challenge to reduce costs and maintain high-quality care becomes a "race to the bottom."

Recently, more providers are considering shared savings programs — taking on both upside and downside risk — as a start into value-based care.

Five surgeons discuss value and risk in orthopedics and how the shift from fee for service will evolve in the coming years.

Note: Responses were lightly edited for style and clarity.

Andre Blom. CEO of Illinois Bone & Joint Institute (Des Plaines): The "value" buzzword will be replaced by "risk" in the next three to five years. This creates tremendous opportunities for orthopedic surgeons who effectively have a significant portion of control in the management of a multitude of business verticals tied to their practice. Thus, I follow any changes associated with value-based medicine very carefully.

David Jacofsky, MD. CEO of The CORE Institute (Phoenix): Although defining the best model of risk-sharing with providers is an ongoing discussion, there remains little question that there is bipartisan support for this cultural shift to continue. Episodic bundled payments, condition-based bundles and population health are all showing good success in program performance in most settings. Although some of these programs will need to shift from "race-to-the-bottom" models to more sustainable and longer-term population health models, that shift is now beginning.

Nicholas Grosso, MD. President of Centers for Advanced Orthopaedics (Bethesda, Md.): We will be implementing our first risk-based contract through Maryland's Episode Quality Improvement Program in 2022 and aim to sign one to two more risk-based contracts by the end of next year. In 2022, we will continue to build and invest in the infrastructure needed to succeed with risk-based contracts. This will not happen overnight, but we are prepared for delayed gratification as we make this exciting transition.

Navin Subramanian, MD. Surgeon at Orthopaedic Associates (Houston): The field of orthopedics is vast and encompasses many pathways. When I take the spectrum of orthopedics in total, I think the biggest game changer will be a move to bundled payment systems to deliver care for surgical procedures. There will be an ongoing larger shift to more outpatient procedures and larger shift to risk-sharing payment systems. This will affect quality of care and may even affect access to care. Risk-sharing models may make surgeons reconsider performing otherwise routine procedures on patients with higher risk stratification. The bundled payment systems may lead payers to either partner with facilities or with physicians; this may influence hospital employment versus private practice models for orthopaedic surgeons. It will be interesting to see how this plays out over the next few years.

Adam Bruggeman, MD. Surgeon at Texas Spine Care Center (San Antonio) and CMO of MpowerHealth (Addison, Texas): Hospitals have negotiated against surgery centers for decades, leading to a dramatic difference in hospital, hospital outpatient department and ASC reimbursement. These practices and policies are driving a significant component of the outpatient migration, in addition to legislation that prevents new physician-owned hospitals from being developed de novo. Physicians will be the new drivers of healthcare for the next decade in terms of bundles and at-risk payments. Hospitals will need to find a way to bring their costs into bundles that make sense for the physicians who manage these arrangements.

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