Newport Beach, Calif.-based DISC Sports & Spine Center has been on the forefront of outpatient orthopedic and spine care for nearly two decades, and it shows no sign of slowing down.
"DISC has seen explosive growth and I think there are reasons why," said Dr. Bray. "There are a number of market forces that I believe will make outpatient spine surgery grow faster than the national predictors; in fact, I'm seeing that rapid expansion happen right now."
DISC was doing 130 to 150 outpatient spine surgeries per year in 2012-13, when the practice partnered with Surgical Care Affiliates; the center then grew to accommodate just under 500 spine surgeries per year. Dr. Bray and his partners bought back DISC in January 2018, and this year the center's surgeons are on track to perform more than 600 outpatient spine surgeries.
"The biggest factor I attribute our growth to is aligning incentives; most of the world is driven by market forces, and we can be successful if everyone is aligned with the same interests," he said.
Question: What do you see as the forces driving spine outpatient today?
Dr. Robert Bray: The insurance companies are a huge driving force for the outpatient spine surgery structure today; they want it. That wasn't the case when I built DISC 18 years ago because at that time insurers would not give us a participating contract. But now they are willing to play ball and actively help us make the move. From their point of view, they want a risk mitigation, a known outcome for the risk across their patient population. We are able to show insurers the data we've collected for the past 16 years, that by moving the case outpatient we can save them money in three ways:
1. On the cost of the event; from start to finish there is about a 30 percent decrease in costs.
2. Patients have fewer long-term complications, readmissions and infections without cherry-picking.
3. Choice of procedure by doctor.
4. Decision-making to choose less invasive procedures
If you add up all three of those things, the net savings to the insurer becomes massive.
Q: When looking at the value equation, how do you ensure patient satisfaction and experience?
RB: Our Net Promoter Scores for patient satisfaction are on the 99th percentile. We are looking at patient-derived data for outcomes and analysis, and ask the patients about if they are happy with their procedure. We let those scores speak for themselves. When patients are happy, you can't argue the outpatient procedures are getting a better outcome. This then meets the insurer's incentive because they can sell improved access policies because they're able to provide good services. If they can show their members achieve good outcomes and are happy with their care across the board, and we're doing it in a sustainable fashion.
Patients want a good outcome and price transparency. The days of being out-of-network are gone; instead, patients want a good doctor who will give them personal care and a good outcome and work with their insurers. The doctors and the health centers have similar goals. They want to be paid fairly for their services. They don't like that they're paid less and less or squeezed tighter and tighter. That's where our current system is falling on its face.
Q: What payer trends are you seeing in the spine space? How are you combating the downward pressure?
RB: Insurers keep tightening reimbursements, and in some cases, reimbursements have gotten so low we can't afford to provide care. There isn't any other sector in the business world that gets 200 to 300 percent in pay reductions and are expected to expand. However, the insurers cutting reimbursement down has created a market for ASCs and what they do: take higher acuity cases to the outpatient environment where they have a better margin and outcomes.
I created a new program at DISC, partnering with Global One and Blue Shield, and expanded that principle to start a project around a global billing packaging. For our scope of services, we package the pricing and partner with the insurance companies so patients pay the insurance company directly. When the patient walks in the door, I say, 'Thank you for having insurance, you're not in the billing cycle. You're not going to get a bill other than the copay or deductible — we'll settle this with your insurance company.'
The patient has access to our center, and we aligned their incentives with ours and the insurer. We are in the process of expanding this to multiple providers and working with United to move forward into this format. DISC receives the payment from the insurer, and we guarantee that everyone is in-network for the agreed rate. Insurance companies love it and they're helping to promote the program.
Q: On the provider side, is there anything the surgeons are doing differently to provide better care or lower costs?
RB: At our center, we do skin-to-skin microscopic procedures every time. We are outcomes driven and participate in cost savings. Right now, we are also creating an artificial intelligence engine to look at the data a little differently. We are trying to take the data derived and examine it across the board so everyone can receive the best outcome. We take all-comers, from professional athletes and executives arriving in private jets to the postman or the dock worker, or patient with insurance from the exchanges. We take Covered California as well. Looking across the board at the population, I can see how many times surgeons at our practice use conservative care and when surgeries are scheduled. I can see how many implants are used and other variables with the AI engine to make sure utilization meets baseline data derived from DISC, plus or minus variants.
Q: With alignment between so many stakeholders in the healthcare system, are there any losers?
RB: The health system and the hospital could be. The answer to that question is a re-alignment. I do believe there will be a merger of outpatient and hospitals, going back to a system of generating care. Right now, people migrate out of the inpatient setting and disappear. Health systems see their patients heading to the outpatient setting, and that's not going to stop. The insurers won't continue to pay high rates, for what can be done more efficiently as an outpatient procedure. The long term answer is redefining the system. The key is meeting everyone's incentives and needs. What we need is sustainable medicine that provides a good outcome and happy patient with cost efficiency that can be repeated across a broad population.