Leaders and physicians in the spine and orthopedic space have a wide range of opinions on where value-based care is headed in the field.
The leaders featured in this article are all speaking at Becker's 20th Annual Spine, Orthopedic & Pain Management-Driven ASC Conference at the Swissotel Chicago.
As part of an ongoing series, Becker's is talking to healthcare leaders who will speak at the conference on June 15-17, 2023. The following are answers from our speakers.
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Question: Where do you see value-based care headed in orthopedics and spine?
Adam Bruggeman, MD. Orthopedic Surgeon at Texas Spine Care Center (San Antonio): It seems clear to me that fee-for-service is the proverbial "race to the bottom" that many attribute to value-based care. We see declining payments every year in addition to not receiving increases in payment based on the actual cost of providing care. Value-based care, when done correctly, can provide new and more stable income streams for physicians who take appropriately calculated risks and provide high-quality care. I anticipate we will continue to see a transition of payment models towards programs that take on greater risk at the physician level, both due to pressure to contain costs from the federal government as well as due to the continually declining fee-for-service payments under those programs.
Akshat Gargya, MD. Assistant Professor of Anesthesiology and Pain Management at the University of Vermont Medical Center (Burlington): In orthopedics and spine, value-based care may involve a shift towards more personalized and patient-centered treatment plans, where the goal is to provide high-quality care that addresses patient pain and discomfort while also managing costs and improving outcomes. This could include greater use of non-surgical interventions, such as physical therapy and interventional pain management techniques, to manage pain and improve function. Additionally, there may be a greater emphasis on preventive care, such as lifestyle changes and exercise, to prevent orthopedic and spine-related conditions from developing or worsening. Advances in technology, such as telemedicine and remote patient monitoring, may also play a role in the delivery of value-based care. These tools can help providers track patient progress and adjust treatment plans in real-time, while also reducing the need for in-person visits and associated costs. Finally, value-based care may also involve a shift towards a more personalized and patient-centered approach to care. This could include greater involvement of patients in treatment decisions, as well as a focus on education and self-management strategies to help patients better manage their pain and improve their overall quality of life. As the healthcare industry continues to evolve, we can expect to see new models of care emerge that prioritize value and patient outcomes over volume and revenue.
Albert Wong, MD. Neurosurgeon at Docs Health (Los Angeles): Value-based care in orthopedic and spine surgery has already transitioned to bundled payments with insurance companies. These bundled payments are designed to incentivize physicians to minimize cost for healthcare of their patients. However, their current data is based upon the short-term global perioperative time. Insurance companies will eventually start incorporating long-term data outcomes as part of their bundled payments for surgeons that have better long-term patient outcomes with quicker return-to-work status, higher percentages of return-to-work patients, and lower incidence of revision surgeries at the index or adjacent levels.
Alejandro Fernandez. CEO at Synergy Orthopedic Specialists (San Diego, Calif.): Value-based care in orthopedics should be about a patient-centered vision to provide quality medical care, at the lowest costs, with the best patient-reported outcomes. But in actuality, the few value-based care initiatives continue to be about payment models that incentivize physicians to provide care for the lowest costs, e.g., ASC versus hospital outpatient departments, less expensive implants, etc. Few organizations record and report patient-reported outcomes, and even fewer insurance payers or employers provide additional financial incentives to physicians and ASCs to improve patient experience and outcomes.
Andrew Lovewell. CEO at Columbia (Mo.) Orthopedic Group: I think to answer that question we have to agree upon what value-based care is. The biggest issue is that nobody agrees on a shared definition of value-based care. However, we can't define value by just saying it is lower cost. If we are creating a race to the bottom, that's not valuable and it's not sustainable. We have to be cognizant of all of the aspects that contribute to value. Those can range anywhere from access, experience, outcomes, cost, etc. As an orthopedic and spine community, if we can align and agree on what the definition is, it will give us a greater ability to truly deliver value-based care. The lens that we examine value through dramatically changes based on the position we occupy in the healthcare continuum. Payers look at "value" in a different light than providers, and so do facilities. Keeping the patient at the center of our focus is key, and understanding how they define value should be our guiding light in the future.
Basil Besh, MD. Surgeon at FORM Hand, Wrist & Elbow Institute (Fremont, Calif.): The healthcare cost curve is unsustainable and payers are more receptive than ever to strategies that deliver high quality at a lower cost. There are several factors which make orthopedics and spine uniquely well-positioned in the current healthcare environment. Those specialties comprise two of the three most expensive inpatient service lines (total joint replacement, spine surgery and cardiology). Both are well suited to shifting to the outpatient realm with the percentage of total joints and spine surgeries being done safely and effectively in the outpatient setting increasing year after year with no signs of slowing down. Finally, both service lines include a large percentage of elective cases, which make them well-suited to bundled payment and shared savings models. It will require continued education of legislators, regulators and payers, but the wind is certainly at the back of these specialties.
Brian Gantwerker, MD. Neurosurgeon at the Craniospinal Center of Los Angeles: Value-based care is a novel idea where we demonstrate how much care we can give for a fixed dollar amount. In a truly free market, this is a good thing. The issue is, the healthcare space is not a true free market. Instead, what the bigger conversation is, what is the expertise, time and judgment of a good physician worth. Insurers and other types of payers instituted value-based care in order to squeeze more time, effort and free care out of physicians rather than get a better product at a good price. You cannot walk into Macy's and walk out with a $3,000 espresso maker for $150. The same should be true for the care physicians give. Once payers and policymakers are serious about discussing the cost of care, myself and most other physicians are ready to talk.
Bruce Feldman. Associate Administrator at SUNY Downstate Medical Center (New York City): Value-based care in orthopedics and spine will continue to be a dominant focus of attention and priority for insurance carriers. As more and more complex procedures move from the hospital to the ASC environment, insurance carriers will link reimbursement to quality outcomes.
Carissa Tyo, MD. Associate Professor of Clinical Emergency Medicine and Director of the Observation Unit at the University of Illinois Hospital (Chicago): Shifting the paradigm of preoperative preparation for complex orthopedic and spine surgeries will be crucial to ensuring the optimum utilization of services around the perioperative period. Advanced screening of anticipated need before the execution of the operative procedure can mitigate the length of stay required by a patient in the postoperative acute phase. Truly preparing the patient for the postoperative recovery can improve the experience of the patient while allowing a seamless transition to the next stage of care and can shorten the length of stay in the acute care setting.
Chris Glover, MD. Anesthesiologist at Texas Children's Hospital (Houston): I believe we will see continued use of enhanced recovery protocols around orthopedics and spine surgery to minimize in-hospital stays. The use of longer-acting local anesthetics for fascial plane blocks, along with the expanded use of cryoablation for orthopedic procedures, should allow for a concerted push to convert more cases into the outpatient space.
Corey Welchlin, DO. Orthopedist at United Hospital District (Fairmont, Minn.): I believe there is significant value-based evidence for ASC work in orthopedics and spine. It would be great if there were standardized benchmarkings ASCs could use to reinforce that.
Craig Popp, MD. Orthopedic Surgeon at Vero Orthopaedics (Vero Beach, Fla.): One area where value-based care involves moving procedures that require only local and moderate sedation to the office setting. Many procedures can be safely and efficiently performed in the office setting. Insurance carriers can work directly with providers and groups to provide high-quality care at a lower cost. For the patient, easy access to safe, predictable and proven care is made available. Providers benefit from the overall efficiencies that they develop, high patient satisfaction and quality care. There are many hand, pain/spine procedures which are easily performed in the office setting.
Daniel Mulconrey, MD. Orthopedic Surgeon at Midwest Orthopaedic Center (Peoria, Ill.): Prior to the COVID-19 epidemic, value-based care was the main focus when discussing the future management of the orthopedic patient. In 2023, the economics of medicine has drastically changed. Hospitals functioning at a deficit, supply chain struggles and the increasing costs of care are plaguing our system. These challenges have forced value-based care to become sidelined, and constricted the available healthcare dollar for the physician. It will be necessary to place quality and cost at the forefront again. Today, surgeons need to focus on improving health-related quality of life measures, which were tracked prior to the epidemic. New baselines for the cost-per-quality-adjusted life year may need to be determined. These current economic plagues will demand a value-based care approach in the future. Today, surgeons would benefit by creating low-cost, high-quality care algorithms to position themselves for a successful future.
Earl Kilbride, MD. Orthopedic Surgeon at Austin (Texas) Orthopedic Institute: In order for value-based care to continue to expand, the providers, especially physicians, need to be primary stakeholders. Physicians drive most aspects of the orthopedic system, all the way from nonoperative conservative care to the implant and facility used to the postoperative regimen. Comprehensive joint replacement is a perfect example that providers will be both cost- and outcomes-sensitive when they are involved in the early decision making.
Elisa Auguste. Administrator at Precision Care Surgery Center (East Setauket, N.Y.) and Board Member of the New York Association of ASCs (Albany): Value-based care will soon become the norm in orthopedics and spine. The cost of orthopedic and spine care is expensive, not just for patients but for providers. Value-based care will help to keep healthcare providers honest and provide high-quality care for their patients utilizing higher and consistent reimbursements for the continuation of that care. Value-based care payments will incentivize providers to increase collaboration in care.
Eric Amundson, MD. Neurosurgeon at NewSouth NeuroSpine (Flowood, Miss.): Third-party payers have traditionally focused on controlling the costs of individual spine surgeries and the related expenses during the subsequent 90 day global period. Many past and current efforts of value-based care, including bundled agreements with which NewSouth NeuroSpine is engaged, focus on the cost-sharing of post-operative care, providing a financial incentive to minimize costly intraoperative and postoperative complications. However, these fail to capture the substantial costs of unnecessary procedures performed. The clock should start when the patient first enters a neurosurgeon's clinic, not when they cross the threshold of the hospital on the day of surgery. Unfortunately, I regularly see unnecessary or excessive spine procedures performed in our community. There's an enormous opportunity for not only improving quality but decreasing costs, thereby maximizing value, by steering patients towards providers that don't over-utilize.
Ernest Braxton, MD. Chief of Neurosurgery at Vail-Summit Orthopaedics & Neurosurgery and Team Physician for the U.S. Ski Team (Frisco, Colo.): Spine surgery ranks as one of the costliest interventions in our healthcare economy. I believe that value-based healthcare models that tie reimbursement to outcomes will become more prevalent in the future. Suppliers that recommend more costly products or services such as artificial intelligence, endoscopic surgery, computer-assisted surgery/robotic surgery or custom implants will need to truly demonstrate value and assume some of the risks associated with an undesirable outcome. I believe that this healthcare model will lead to a healthier society while reducing overall healthcare spending.
Geoffrey Van Thiel, MD. Orthopedic Surgeon at OrthoIllinois (Rockford): Value-based care will continue to focus on cost, quality and outcomes. However, the near future will see a move from episodic bundles around specific case types to population health strategies around the orthopedic and spine service lines.
Han Jo Kim, MD. Spine Surgeon at the Hospital for Special Surgery (New York City): When it comes to value-based healthcare in orthopedics and spine, I believe it comes down to the original definition of value, which is quality over cost. In the next few years there will be increased pressure to move orthopedics, and a portion of spine care, to the ASC setting. Naturally, this will decrease costs, and therefore increase value. Centers will be forced to "lean" their processes, whether with enhanced recovery pathways or expedited processes, in order to decrease length of stay, shorten operative times and decrease the time it takes for patients to recover from operations all while upholding quality. Centers will have to be creative and efficient in working within and leveraging their multidisciplinary teams and skill sets in order to deliver greater efficiency in care delivery, and decrease the costs for overall episodes of care for a given operation. These will be exciting times, and I believe research will be the cornerstone with which to validate these mechanisms.
Jami Osterlund. Director of Surgical Services at Hill Country Surgery Center (Cedar Park, Texas): I feel that value-based care in orthopedic and spine services will likely cause a universal standardization of processes and evidence-based practice protocols to ensure safe patient outcomes and high-quality care. We are moving away from things being a particular way because that was the physician's preference or the way we've always done it.
John Prunskis, MD. CEO and Medical Director at the Illinois Pain & Spine Institute (Elgin): As long as hospitals are two to five times more expensive for procedures and surgeries that are also done in an ASC, value-based care for spine surgeries and procedures should be and will be driven to ASCs. The exorbitant fees that hospitals are allowed to collect compared to ASC fees for identical procedures and surgeries is one of the reasons for Medicare going bankrupt.
Joshua Rosenow, MD. Director of Functional Neurosurgery at Northwestern Medicine (Chicago): Value-based care continues to suffer from difficulties defining the outcomes on which the quality of care is measured. As organizations negotiate value-based care contracts with insurers, providers and payers will continue to push for the metrics they favor. Moreover, what is the timeframe for these outcomes? Is three or six months enough if functional measures are utilized, or do these need to be sustained at 12 months or longer? Arguments such as these will continue to hamper widespread adoption of value-based care in spine surgery.
Kyle Anderson. Vice President of ASC and Ancillary Services at Ortho Rhode Island (Providence): The adoption of value-based care allows for the proverbial "triple win" to patients, providers and payers. These care models encourage innovation and reward evidence-based medicine while creating an alignment of practice patterns and economics. The most successful provider groups in orthopedics and spine understand the critical importance of technology and data platforms to support the transition from fee-for-service. Those who are forward-thinking accept that value-based care is not a simple one-for-one exchange of historical models and are actively collaborating with platforms and payers. Advances in orthopedic value-based care will continue to be diverse in structure while cost-reducing methodologies, such as migration to ASCs and data-driven efficiencies, will support their success.
Matthew Dellaquila, MD. Vice Chief of Anesthesia Operations at Henry Ford Jackson (Mich.) Hospital: Perioperative medicine and anesthesiology will be at the forefront as value-based care evolves. As healthcare dollars dry up, quality of care and the financial implications behind that will necessarily come into focus, most especially in orthopedics and spine procedures. These procedures have a massive increases in their expense and morbidity when quality falls off of the curve — instances such as surgical site infections, poor pain control, avoidable blood transfusions and other perioperative morbidities are huge opportunities to improve quality and care, and will be heavily focused on by payers gearing up towards value-based care in the future. Areas where anesthesiology can influence these parameters are represented in the perioperative surgical home — making sure patients have good preoperative, intraoperative and postoperative optimization of care. Preoperatively, this means managing a patient's medical condition to make them the best they can be on the day of surgery. By having diabetes under control, instances of surgical site infections are lower. Treating anemia preoperatively to avoid an intraoperative blood transfusion is another way that preoperative optimization could help with both value-based care and cost cutting. Many other examples exist. Intraoperative solutions to cut down on surgical time and transform surgeries from inpatient to short stay or outpatient also will be of paramount importance to value-based care. These solutions are things such as deciding on a spinal, regional or general anesthetic – these decisions can influence postoperative pain and nausea and secondarily influence risks of deep-venous thrombosis and other perioperative comorbid risks. Finally, postoperative care — such as choosing an anesthetic that encourages early mobility, such as a peripheral nerve block and/or catheter, a firm pain control regimen and structure that prevent bouncebacks, and a safety net in follow-up — will further improve compliance with value-based care. By focusing on perioperative medicine, the savvy surgery center can stay ahead of the curve financially while improving quality outcomes for their patients.
Michael Graziano. Administrator at Clifton (N.J.) Surgery Center: Value-based care is likely to become more prevalent in the coming years as large healthcare systems shift from fee-for-service to value-based models. It is likely to have a significant impact on the way care is delivered with a focus on improving outcomes, reducing costs and enhancing the patient experience. It will place an emphasis on providers to develop additional methods to track and report outcomes to evaluate the effectiveness of their treatments while prioritizing operational efficiencies and new technologies to keep costs down.
Mihir Patel, MD. Orthopedic Surgeon at OrthoIndy (Indianapolis): In orthopedics and spine, the value-based care model will promote additional efficiencies in delivering care. For providers, value-based care offers the opportunity to highlight superior outcomes with their internal processes. For payers, value-based care will help their covered lives choose the right providers and systems for the chance at the best outcome. For both, arbitraging the value-based care data can lead to spectacular growth.
Nicholas Street, MSN, RN. Self-employed Travel Nurse. Value-based care, where healthcare providers are compensated based on the quality of care they provide rather than the volume of patients they see, is gaining momentum in the orthopedics and spine specialties. The focus on value-based care is expected to improve patient outcomes, reduce healthcare costs and increase efficiency. In orthopedics and spine, value-based care is expected to result in more personalized care, with providers tailoring treatments to meet individual patient needs. This may involve the use of new technologies, such as 3D printing and augmented reality, to create custom implants and assist in surgical planning. In addition, value-based care is expected to bring greater focus to patient-reported outcomes, which allow providers to better understand the patient's overall health status and how they are responding to treatment. This will likely lead to a greater emphasis on patient-centered care, with providers working closely with patients to develop care plans that meet their specific needs and preferences. Overall, value-based care is expected to lead to a shift towards quality over quantity of care, with providers focusing on improving clinical outcomes and enhancing the patient experience. This is an important step towards creating more effective, efficient and patient-centered healthcare systems in orthopedics and spine.
Philip Louie, MD. Spine Surgeon at the Center for Neurosciences and Spine at Virginia Mason Franciscan Health (Seattle): Procedure reimbursements are clearly on the decline. CMS has published reports indicating ongoing decreases in procedure reimbursements. Ultimately, I fear that the decline in reimbursements may result in negative consequences that will force providers to shoulder some of this financial burden. The economic landscape of our healthcare system is already in some disarray. Our healthcare system, as a whole, is struggling on several fronts right now, and the financial losses have compounded the situation. We have seen several large hospital systems shut down service lines and other smaller medical centers close their doors. Many of us have watched our colleagues walk away, either by choice or as a result of cost-cutting measures. On top of that, each and every day, we are facing short staffing, burnout and hospital capacity concerns without a clear light at the end of the tunnel. In a world where socioeconomic disparities of care have been recently highlighted, we have made a large effort to close that gap and reach a diverse population to provide care. Decreased procedure reimbursement could also potentially limit critical access for Medicare and Medicaid patients, thus marginalizing a population that is currently being further marginalized by larger macroeconomic forces. Additionally, we have spent the past few years building value-based care pathways, developing quality-based programs and academic pursuits to innovate — and these programs may have to take a back seat in order to provide the greatest volume of care to catch up financially with these additional cuts. Thus, placing additional hurdles to create the value-based programs that many of these payers (CMS included) have urged us to create and implement. Ultimately, I think reimbursement should focus on targets around quality and cost-effective care, rewarding those focused on these results, rather than institute broad widespread cuts in reimbursement.
Roland Kent, MD. Spine Surgeon at Northwest Specialty Hospital (Post Falls, Idaho): It is important as orthopedic and spine surgeons that we work with our patients and our colleagues to play an integral role in defining what value-based care actually means. If we stick our heads in the sand, then others will define this for us and our ability to provide adequate care to our patients will be negatively affected.
Tammy Smittle, BSN, RN. CEO at Stonegate Surgery Center (Austin, Texas): I believe that value-based care in orthopedics and spine can improve patient outcomes and reduce costs by ensuring that patients receive the most effective and appropriate treatments for their conditions. Value-based care may involve patient-centered care, evidence-based care, continuity of care and team-based care. My ASC currently works on team-based care for our total joint patients. Our team is comprised of anesthesia, for the appropriate blocks; surgeons that are diligent with appropriate patient selection; certified technicians and nurses with total joints; and a physical therapy group that gets our patients up for the first time, as well as transferring them to their cars at discharge. The patients win when value-based care is the focus.
Thomas Scully, MD. Neurosurgeon at Northwest Medical Center (Tucson, Ariz.): I think value-based care in spine will be increasing in the future. In many ways, this will be tied to more surgeons being employed, either by hospital systems, or via private equity models. For smaller private practice groups, the entry into value-based care is steep and not without cost. However, as private practice dwindles,the bigger employers will be contracting in more of a "silo" fashion. Hospitals, surgeons, physical therapists, etc., will all be rolled into one carve-out for the big insurers.
Timothy Lubenow, MD. Anesthesiologist at Rush Pain Center (Chicago): From a perspective of the Medicare component of patients, I definitely see CMS using measures of improvement in function such as Promis 29 scores as evidence that our therapies are working. For example, everyone who has an radiofrequency ablation of lumbar facet region would have to complete these scores to document functional improvement. Without improvement in function or opioid use, I suspect they will not pay.
Tung Ha, DO. Neurosurgeon at PeaceHealth St. Joseph Medical Center (Bellingham, Wash.): In concept, value-based care makes sense to me. One brings their car to the mechanic to make it run better, not for it to run worse. Likewise, patients undergo surgery to get better, not to get worse. The challenge is that "making better" or "adding value" is an outcome that needs to be clearly defined. This outcome needs to be agreed upon by all stakeholders (surgeon, patient, and payer) and accurately assessed and quantified. As long as there is variability in surgeon judgment, surgical technique and patient selection, the outcome will be all over the board. Some patients will get better, and some will be worse after surgery. To have reproducible outcomes, it is helpful to minimize the amount of variability in surgical technique and patient selection. Technology, such as robotic-assisted spine surgery, has made pedicle screw placement more accurate and reproducible between surgeons. Similarly, I suspect that payers will use AI to create treatment algorithms to determine which patients would benefit from surgery the most. Hospitals will still want surgeons to do large, complex operations for the higher reimbursement. However, if there's a perceived complication and a financial penalty, the hospital will hold the surgeon's feet to the fire. Thus, this paradigm will likely influence the surgeon's patient selection. The result will be a more efficient system where patients who get surgery have better outcomes with an overall decrease in healthcare expenditure. By virtue of distributing healthcare to patients in a value-based manner, this runs counter to our society's current desire to increase equity in healthcare, where more resources are provided to those who are the sickest or desire intervention regardless of "appropriateness." You cannot have your cake and eat it, too.
Vladimir Sinkov, MD. Spine Surgeon at Sinkov Spine Center (Las Vegas): Value-based care has been promoted in healthcare in the U.S. for at least the past two decades now. The biggest problem with this notion has been the fact that it was never clearly defined for whom they were trying to create the value — the patient, the insurance company, the government, the society as a whole, or the healthcare providers. As you can imagine, the value of healthcare would be quite different for each of those entities. Theoretically, it should be the value for the actual consumer of healthcare — the patient, for whom the value is the product of the quality of care plus the patient experience at a given cost. Realistically, however, the main driving force and motivation behind this initiative has been to reduce the costs to the insurance companies while maximizing profits for insurance companies and for large hospital systems or large physician groups. What I have seen happen over the past two decades instead is that the healthcare quality for the patient has become worse and providing healthcare services has become more expensive, more difficult and less efficient, mostly due to ever-increasing regulations and overhead costs. The value to the insurance companies, however, has been tremendous — as a group, they have been one of the most profitable sectors in the U.S. every year over this period of time, even during recessions and pandemics. The rise in insurance premiums and the increase in costs to provide healthcare will likely continue. There is a great financial incentive for the health insurance companies to keep things as they are right now. They will continue introducing many initiatives to promote value to everyone else, which will likely involve some type of an attempt to limit care or to shift the financial risk away from the insurance companies and onto the physicians, hospitals or patients. The quality of care and access to care for the patients will likely continue getting worse. As a doctor, I am only interested in providing value to my patients by providing the best quality of care I can. I will continue doing so to the best of my ability in this interesting and ever-changing healthcare environment.
Yeshvant Navalgund, MD. Pain Management Specialist at National Spine & Pain Centers (Glen Burnie, Md.): The most important trend in value-based care in orthopedics and spine is the growing emphasis on patient engagement and shared decision-making. This will mean that patients will take a more active role in their treatment and work collaboratively with their surgeons to make informed decisions about not only the location of their care, but also the economics related to their overall treatment options.