Pennsylvania Hospital in Philadelphia has always aimed to provide high value care, said Chair of the Neurosurgery Department William Welch, MD.
However, the definition of "value" has changed during his time in practice to include the financial side of the value equation. Here, Dr. Welch discusses how his role has evolved over the past few years and where the neurosurgery department is headed in the future.
Question: How has your role as a spine department leader evolved over the past two to three years? How have your responsibilities changed?
Dr. William Welch: There has definitely been more economic pressure over the years. There is a pressure from below and above now. The pressure from below is the health system; we have to keep trying to control costs as reimbursements decrease. There is a pressure from above; we put pressure on vendors to lower costs, and frankly now we look at just about everything we do in a scientific and rigorous way to make sure patient care isn't compromised and we reduce the variation in an appropriate and scientific way.
At Penn Medicine, we have really placed increased emphasis on quality and the quality-value equation. That has been a tradition at Penn, one of the nation's first hospitals. For the past 250 years, the hospital has based its reputation on the delivery of quality surgeons, and now we take on the value equation of delivering the highest quality care at the most reasonable cost.
Q: How do you determine what is worth the investment when it comes to new technology?
WW: We examine the literature. Over the years we have noticed that you have to pay attention to the sponsor of the paper. Companies that produce a new product have to spend some amount of money to conduct the studies that show value, either the reduction of time in the operating room, lower readmission rates or other factors that allow them to ascribe value or cost. However, that's not necessarily representative of the cost savings that Penn's members would have because we have different cost structures even within our health system; it costs more to do the same procedure at one hospital than another. We found the only way we can dig into it meaningfully was to do the hard work of looking at ourselves.
We recently published a paper on the amount of time it takes to perform a microdiscectomy. It's a shocking amount of time when you account for the surgeon's time, nurse's time, surgical tech's time and the hospital's time. The only way we could get that information was to have a researcher follow me around and make notes on the patients. I think the cost information is very regional and can be biased depending on the product or treatment. The only way we could find the information out was to conduct the study on our own.
Q: What do you consider your No. 1 priority to ensure departmental success?
WW: Access to care. The ability for our patients to contact the appropriate providers and for us to see the patient in a timely manner is the number one priority. What does the patient need? What is the patient expecting? What will the patient's insurance allow? Who is the best initial person to see the patient? Sometimes the best initial person is the neurosurgeon or the orthopedic surgeon and sometimes it's the non-operative specialist, nurse practitioner or physician's assistant.
We try to meet the patient's expectations while providing high-quality medical care. It's very time-consuming. One of the ways we have found to triage the patient is through a nurse navigator. One of the challenges has been the cost of this program, but if you get the patients better outcomes then you are saving costs downstream.
Q: What is the biggest challenge you are facing as head of the department and how are you overcoming that?
WW: While economics is always a challenge, a bigger challenge for our group is quality outcomes. We take the patient-reported outcomes scores very seriously and look at a number of quality metrics, including readmissions. We have strongly implemented an enhanced recovery after surgery program. This has been a tremendous bonus for us; while it takes a lot of upfront time, it engages patients with their own outcomes. I have found it very beneficial.
Q: What are the department's goals for 2019 and what is your vision moving forward?
WW: Our goals and our vision centers around the patient experience and quality. We really want to maximize the quality of care we deliver in a programmatic fashion and we want to maximize the patient experience.