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Surgeon Executive Keynote: Volume and Value - OMTEC 2018
- 2. Riverside Health Advisors Value in Healthcare Mark I. Froimson, MD, MBA Principal, Riverside Health Advisors Immediate Past President, AAHKS Former, Chief Clinical Officer, Trinity Health Former, President, Euclid Hospital, a Cleveland Clinic hospital
- 3. Riverside Health Advisors COI Disclosure Consultant J&J myoscience UOC Flexion Equity Clarify Health myoscience Pacira Splash Financial Concord Health Partners Indago SoberGrid Leadership/Board Positions AAHKS Pacira Pharmaceuticals Indago Thrive Peer Support AngelMD Editorial Boards/Reviewer JOA JBJS
- 4. Riverside Health Advisors • Thank You • The Challenge • The Talk of Value • C Suite Priorities • Better Conversations • Thank You Agenda
- 5. Riverside Health Advisors • What we do matters • We improve lives • We relieve pain • We restore motion • We restore function • We return people to work and play • We allow people to enjoy their families and milestone events Thank You for All You Do for Our Patients
- 6. Riverside Health Advisors • We are part of a great system of care that makes all this possible • We each play a role and have a duty to preserve and improve it • We work very hard to serve our patients needs • We constantly strive for better methods • We listen to our patients and try to give them what they want • We innovate, bringing new solutions to bear • We give our all, after hours, during the day • We never put our interests ahead of those of our patients Healthcare Ecosystem: Orthopedics in Particular
- 7. Riverside Health Advisors • We provide a safety net for societal problems • We leave no patient behind • We have made tremendous advances • We can do more now that ever before • We can solve more problems with less effort • We know more about the underlying science/genetics of problems • We have more data about what works • We can personalize medicine for our patients Healthcare is an Amazing Field
- 8. Riverside Health Advisors • Thank You • The Challenge • The Talk of Value • C Suite Priorities • Better Conversations • Thank You Agenda
- 9. Riverside Health Advisors • Total joint arthroplasty (TJA) is one of the fastest growing elective operations in the United States. • Over 1.3 million total hip arthroplasty (THA) and total knee arthroplasty (TKA) procedures are performed in the United States each year. • Top expenditure for CMS, over $7B in 2015 • $25,000 per episode • 500,000 episodes • $15-$20 billion dollars are spent on arthroplasty procedures in the United States every year Arthroplasty (Orthopaedic ) Demand Continues to Increase Because it Works–Our Success Attracts Attention
- 10. Riverside Health Advisors 9©2016 Trinity Health - Livonia, Mich. Musculoskeletal Conditions are Common and Costly, Treatments are Successful and In Demand 9% 13% 28% 31% 54% 0% 20% 40% 60% Cancer Diabetes Respiratory Circulatory Musculoskeletal Proportion of United States Population Reporting Chronic Medical Conditions, 2012 Source: National Center for Health Statistics, National Health Interview Survey, 2012 29% 16% 14% 29% 18% 0% 5% 10% 15% 20% 25% 30% 35% Hospital [2] Physician Office [3] Outpatient [4] Emergency Department [5] Total ProportionofTotalDiagnoses1 Musculoskeletal Diagnoses as a Proportion of All Diagnoses for Care Received, All Care Facilities, United States 2010/2011 [1] Includes all possible diagnoses. The number of diagnosis variables varies in the databases (NIS up to 25; NAMCS up to 15; NHAMCS_OP up to 3, NEDS up to 15). [2] Source: HCUP Nationwide Inpatient Sample (NIS). Healthcare Cost and Utilization Project (HCUP). 2011. Agency for Healthcare Research and Quality, Rockville, MD. www.hcup-us.ahrq.gov/nisoverview.jsp [3] Source: National Ambulatory Medical Care Survey (NAMCS), 2010. www.cdc.gov/nchs/ahcd/ahcd_questionnaires.htm April 23, 2013. [4] Source: National Hospital Ambulatory Medical Care Survey_Outpatient Department (NHAMCS_OP), 2010. www.cdc.gov/nchs/ahcd/ahcd_questionnaires.htm April 23, File: G1E.0.1.png $213 Billion in Direct Care Costs in 2011 Growing at 6-9% per year
- 11. Riverside Health Advisors U.S. Healthcare is Expensive, Requires Deficit Spending and is Not Delivering ‘Optimum Value’ per Dollar Spent 10 PerCapita Spending AverageLife Expectancy Unite d State s Medicare and Medicaid spend > $1.1 Trillion
- 12. Riverside Health Advisors Dartmouth Atlas A Description of Variation in Medicare Spend per Beneficiary by Geographic Region
- 13. Riverside Health Advisors Variability in Quantity of TKA by Region 5 – 15 per 1000 people (3x) “Quality in healthcare means doing the right things right.” “Although performance quality is important, so too is the quality of clinical decision-making: doing the right thing.” “Variation is an important indicator of problems in the quality of decision-making.” http://www.dartmouthatlas.org/data/topic/topic.aspx?cat=22
- 14. Riverside Health Advisors Implicit Conclusion There isn’t that much physiologic variability Disease incidence isn’t that varied So some conclude that some Arthroplasties being performed must be discretionary
- 15. Riverside Health Advisors Variability in Cost to Deliver • 29 high-volume U.S. hospitals primary TKA w/o CC • Methods: TDABC calculated using internal costs/claims • Results: cost of TKA varied by a factor of about 2 to 1 • Conclusions: The large variation in costs • Some of the spend in each case must be discretionary—not adding value!
- 16. Riverside Health Advisors The Economic Criticisms of Arthroplasty: The Opportunity for Providers/Payers Problems • We are spending “too much” on Arthroplasty as a society • There is too much variability in spending on Arthroplasty • The variability in incidence cannot be explained by disease incidence • Each episode, on average, costs too much Solutions • Do fewer Arthroplasties—shared decision making • Reduce the variability in cost—narrow the distribution • Reduce the mean episode cost
- 17. Riverside Health Advisors Porter and Teisberg—2006 ‘Value Based’ Healthcare The U.S. healthcare system is in crisis. At stake are the quality of care for millions of Americans and the financial well-being of individuals and employers squeezed by skyrocketing premiums. —Not to mention the stability of state and federal government budgets.
- 18. Riverside Health Advisors Healthcare System may not be in Crisis, but it is Certainly Under Siege
- 19. Riverside Health Advisors • Thank You • The Challenge • The Talk of Value • C Suite Priorities • Better Conversations • Thank You Agenda
- 20. Riverside Health Advisors Porter and Teisberg—2006 ‘Creating Value Based Competition on Results’
- 21. Riverside Health Advisors Our Relationship with Money • Healthcare is a business • Each entity–health system, physician, payer, industry, employee–has an economic incentive • But, we think it makes us somehow impure to talk about the financial impacts of what we do • We deride ‘bean counters’ • We see ourselves as altruists–so we talk about “value” • Value in healthcare should be measured by what we as individuals and a society are willing to pay for, and how much is borne by each, by me, and by society.
- 22. Riverside Health Advisors June 20, 2018 l 21 Patient Purchaser Health System Surgeon Industry Regulator Payer Healthcare Ecosystem Changing Relationships Cost for one = profit for another and one person’s waste is another’s business Who provides Value? Value to Whom? What is the Patient Willing to Pay for? $3 Trillion Opportunity/Risk
- 23. Riverside Health Advisors Volume to Value: Repeat
- 24. ©2014 Trinity Health. All Rights Reserved. 23 The Volume to Value Transition: (circa 2015) Is this the right language? 23 Population Value Service Volume Producer- Centered People- Centered TOMORROWTODAY ©2015 Trinity Health - Livonia, MI
- 25. Riverside Health Advisors How are We Using the Power of Language? “Uttering a word is like striking a note on the keyboard of the imagination.” – Ludwig Wittgenstein “Words, like nature, half reveal and half conceal the soul within.” – Lord Tennyson “Words are, of course, the most powerful drug used by mankind.” – Rudyard Kipling 24©2016 Trinity Health - Livonia, MI
- 26. Riverside Health Advisors 25©2016 Trinity Health - Livonia, Mich. Muller Lyer Illusion: Can we trust what we think is true? Which line is longer?
- 27. Riverside Health Advisors 26©2016 Trinity Health - Livonia, Mich. Muller Lyer Illusion: Which line is longer?
- 28. Riverside Health Advisors Perspective (and Punctuation) is Also Key in Language How would you punctuate this sentence? A woman without her man is nothing 27©2016 Trinity Health - Livonia, MI
- 29. Riverside Health Advisors Perspective (and Punctuation) is Also Key in Language How would you punctuate this sentence? Women: A woman: without her, man is nothing Men: A woman, without her man, is nothing 28©2016 Trinity Health - Livonia, MI
- 30. Riverside Health Advisors Type I Visceral, fast, intuitive Easy, low energy Type II Analytic, slow, rational Hard, high energy We come to our conclusions, and then find evidence to support what we already decided 29©2016 Trinity Health - Livonia, MI How Do We Think and Come to Our Views?
- 31. Riverside Health Advisors • Clinical – better care • Financial – less cost • Operational – more efficient • Human Resources – less burnout • Mission – societal benefit • IT – data driven • Project Management – what is achievable • Process Improvement – quality and safety • Strategy – market dominance • Legal – compliance • …Tower of Babel… 30©2016 Trinity Health - Livonia, Mich. Languages of Healthcare: So, what do we mean by value? Are you multilingual? How many languages do you speak?
- 32. Riverside Health Advisors What is Value? What is the Role of Price? • What are we willing to pay – Price • The amount of value I assign to a good or service is represented by the price I am willing to pay • Price as defined by • Money I will part with • Time I will spend choosing or obtaining the item • Political or emotional strain of the choice I make • Opportunity cost of what I am not doing or buying • Future spend that will be required to maintain this choice
- 33. Riverside Health Advisors Moral Hazard of Health Insurance: We don’t pay directly for healthcare • If someone else is paying for it, I want as much as I can get • I am not price sensitive when • I am not paying for it, or • I think I already paid for it • Current insurance is a combination of 2 distinct things • Insurance for the unexpected—emergencies, surgery • Prepaid health care for anticipated expenses—primary care, screening • When I can’t separate these out, I have a risk of feeling entitled and dissatisfied with my deal—co-pays, deductibles
- 34. Riverside Health Advisors What Type of Good or Service is Joint Replacement? Necessity? Discretionary? Commodity? Differentiated? Public good? Private good? Free market? Regulated market?
- 35. Riverside Health Advisors Is Healthcare (Joint Replacement) a Right? • Should everyone have equal access? • Who decides how we allocate resources? • Can you refuse to do a procedure on a noncompliant patient? • How do we think about the emergence of ‘hard stops’ • BMI > 40 • Smokers • Substance Use Disorder • We don’t really know how to set up a market for orthopedic services if we don’t agree on these issues
- 36. Riverside Health Advisors Current Delivery Cycle with FFS Payments Flowing To and From Various Participants Leads to Current State 35 Proprietary & Confidential Community-Based Care Acute Care Post-Acute Care 06/20/18 Payers $$ pharma Purchasers $$
- 37. Riverside Health Advisors Distribution of Payments from CMS for a TJR Does not seem Right, and Gets Surgeons’ Attention SNF $6000 Surgeon $1200 Hospitalist $400 Implant $4800
- 38. Riverside Health Advisors As payment per case drops, surgeons protect their salary by increasing the number of cases they do per day $2000 per case of a $25,000 total spend If I do 300 cases, my surgical billing is $600K and the total spend $7.5M $1000 per case of a $24,000 total spend If I increase to 500 cases, my billing drops to $500K, but total spend now hits $12M Paying surgeons less increases total spend (if some care is discretionary) Paying Surgeons Less Has Cost More Joseph Bernstein, MD, MS; Peter Derman, MD, MBA Orthopedics. 2012;35(12)
- 39. Riverside Health Advisors Increase productivity and volume—do more cases Surgeons seek employment or alignment status Guaranteed salary De-risk from the market Co-management arrangements, directorships Surgeons seek supplementary payment 10-50% of income is derived from sources other than FFS Ancillaries, ASC, Royalties, Consulting Alternate Payment Models Provide some hope Reconciliation bonus if own the bundle 50% bonus Consequence of Declining Relative Payment
- 40. Riverside Health Advisors • Physicians are incentivized to do unnecessary things • Procedures are more highly valued than cognitive services • We do more to patients than they need • Patients aren’t good at knowing what recommendations to follow • How many transactions in your life are fee for service, despite an asymmetry of information? Vilification of Fee For Service
- 41. Riverside Health Advisors It may not be FFS that is Wrong, but Rather the Deconstruction of a Composite Product 40 Proprietary & Confidential Community-Based Care Acute Care Post-Acute Care 06/20/18 Payers $$ pharma Employer/Purchasers $$ DRG Part D Part B Part A Part A
- 42. Riverside Health Advisors 2010 PPACA Center for Medicare and Medicaid Innovation CMS Introduction of Alternative Payments to explore new payment models for integrating care ACO Bundled Payments for Care Improvement
- 43. Riverside Health Advisors Premise: When change in health status demands intervention, managing the entire episode is preferable to fragmented care delivery Tactic: Redesign the approach to perioperative care–care coordination and patient and provider engagement– yields better care at lower cost Strategic Imperative: Providers who master this approach create value and will have a competitive advantage in the marketplace Healthcare Reform: Approaches to Care Two Paradigms in Healthcare Reform Heal… Heal… Epis… Epis… Heal… Heal… Epis… Heal… Heal… HealthStatus Baseline= 40% Episode= 60% Managing baseline health needs (population health): preventive care, chronic care, health maintenance Managing episodes of care: hospitalizations, surgical interventions (joint replacement) 1 2 Medical Home/ACO Episode Management/Bundles 42 REDUCE # REDUCE $ Per
- 44. Riverside Health Advisors ACOs are Under Pressure for Poor Performance
- 45. Riverside Health Advisors • Single payment/price for a group of services related to the complete treatment of a medical condition • Target price is 2-3% discount off historic (unmanaged) cost • If cost is lower than target, provider keeps the difference • If cost is higher, provider must rebate difference • Provides opportunity for physicians and providers to be rewarded for the value provided by their services 4©2016 Trinity Health - Livonia, Mich. Bundled Payment Programs have been Performing Well
- 46. Riverside Health Advisors H Aug Sep Oct Nov Dec O HOO O Jan Feb Mar Apr May Jun Jul O TJR Readmit? Pre- AdmitOrthoPrim Care Prim Care Rehab/ Snf/hc 7 days pre 30-90 days post $ $$$ one price for episode $$ Care coordinator June 20, 2018 l 45 • Composite product, includes all care over a period of time–“episode” • Triggered by a hospitalization/surgical event • Cost reflects the resource utilization that occurs from all sources Bundled Payments for Individual Services of Episode
- 47. Riverside Health Advisors Patients Expect us to Deliver Care as a Complete Episode, Inclusive of all of the Interventions that are Needed Provider Centered: Bundled Payment Patient Centered: Complete Care Reputation Access/Appt Education Evaluation Appropriateness Clinical Optimization Risk Mitigation Shared Decision Efficient Processes Operative Excellence Clinical Pathways Outcomes Rehabilitation Recovery
- 48. Riverside Health Advisors Complete Care TJA: Using Evidence to Reduce Resource Consumption in Care Delivery Patient selection perioperative surgical home Standardize preoperative optimization Standardize OR teams and process flow Better blood management/TXA, pre-op screen Increase multimodal pain management and local infiltration, No IV PCA Evaluate routine X-ray use in PACU No more daily lab draws No Ice Man or bipolar sealer No bulky dressing, no staples No routine Foley catheter Rapid recovery mobilization: standard DC criteria Post acute rationalization Home health utilization criteria
- 49. Riverside Health Advisors Eliminating Avoidable Spend Enables Success in Episode Based Payment Models Unnecessary Labs and Imaging Unnecessary Consults Overly Expensive Implants/Drugs Complications/Readmissions Excess LOS/OR Time Excessive Spend on Rehabilitation
- 50. Riverside Health Advisors Managing the Episode: Four Pillars • Patient selection and engagement • Physician leadership and team based care • Care optimization through pathway and protocol development and adherence • Clinical intelligence: • Data analytics, predictive modeling and decision support
- 51. Riverside Health Advisors Cost Reduction in TJR DRG 470 ACE and BPCI Programs BPCI • reduced per episode spending • maintaining quality and improving satisfaction $864 reconciliation per episode savings Surgeon led bundles did better ACE 26,785 BPCI 21,208
- 52. Riverside Health Advisors Cost (revenue) Time 51 The Business Case: Value created by better episode management/care redesign should accrue to those who generate it Traditional fragmented delivery Value creation New Model of Care Portion of savings to payer Available margin for provider
- 53. Riverside Health Advisors Value can be “created or shifted” by owning the bundle —decrease spending downstream Hospital Centric 52 Proprietary & Confidential Community-Based Care Acute Care Post-Acute Care 06/20/18 Payers $$ pharma Hospital centric Purchasers $$
- 54. Riverside Health Advisors Value can be “created or shifted” by owning the bundle —decrease spending downstream Physician Centric 53 Proprietary & Confidential Community-Based Care Acute Care Post-Acute Care 06/20/18 Payers $$ pharma Purchasers $$ Physician centric
- 55. Riverside Health Advisors • Some selected patients are avoided • High medical or surgical risk • Poor support system • There was considerable unnecessary spend in the system • DRG system consequence • Post acute spend, physical therapy • More efficient processes can be identified to streamline care • Physicians are best at allocating resources during the episode • Managing performance risk • True value of innovation/advanced technology can be assessed • Assumptions we had about what care is needed have been called into question – the door is open Episode Based Payment Design: Some early lessons learned
- 56. Riverside Health Advisors • Thank You • The Challenge • The Talk of Value • C Suite Priorities • Better Conversations • Thank You Agenda
- 57. Riverside Health Advisors What’s Driving Hospital and Health System Decisions? • Being relevant to • Payers • Physicians • Patients • Financial sustainability—Most care is FFS • Margin—revenue minus expenses • Balance sheet • Bond rating
- 58. Riverside Health Advisors What’s Driving Hospital and Health System Decisions? • Increasing Market Share • Reputation and Product Mix • Quality and Safety • Compete for Patients and Physicians • Increasing Revenue • Contracts and Product Mix • Reducing Cost of Goods Sold • Workforce Issues • Sustainability • Turnover • Shift to Value Based Care
- 59. Riverside Health Advisors Value Based Care: Success of bundles has gotten the attention of C-suite • An Imminent Shift: Almost three-quarters (73%) of C-suite executives surveyed completely or somewhat agreed that providers must immediately begin shifting their focus from volume to value. • Disruptive Potential of Value-Based Purchasing: Nearly four in ten respondents (38%) completely or somewhat agreed that VBP is likely to become a truly disruptive innovation. • Crucial to Win Hearts and Minds: Fully engaging their doctors was seen by surveyed C-suite executives as the top barrier to VBP participation, selected by half of respondents.
- 60. Riverside Health Advisors • Alternate Payment • ACOs and bundled payments create value to be harvested • Shift in Site of Service • Outpatient—lower cost in bundled environment • Digital connectivity—manage patients more effectively • Smart Tools to reduce outliers and increase efficiency • Robots, AI and other differentiators—attract physicians • Workforce • Physicians and clinicians—better use of clinical teams Current Trends and Interests Deriving from this Recent Experience
- 61. Riverside Health Advisors • Complete portfolio of services • Geographic coverage for payers • Consolidation of providers • Physician employment and alignment • Capital projects • Access Points – Urgent Care, ASCs • Integration of product lines – post acute, home care • Contracting with payers • Narrow networks Keys to Market Share
- 62. Riverside Health Advisors • Complete portfolio of services, acute, post acute, home • Site of service optimization HOPD > ASC • Product mix—high profit service lines • Cardiac, Oncology, Orthopedic, Neuro • Payer Mix—contracting with private payers • Narrow networks • High prices without transparency • Discount off Charge Master • Recruiting high profile physicians Margin: Increased Revenue
- 63. Riverside Health Advisors • Pharmacy • Formulary restrictions • Generic therapeutic substitution • Supply Chain • Limit vendors–price concessions for volume • Limit new technology • Operational Efficiency • Throughput of patients per unit of time • Eliminate waste, resource consumption Margin: Cost Reduction
- 64. Riverside Health Advisors • Physician burnout • Toll of change and multiple false starts • EMR and other non-value-add technologies • Nursing turnover and retention • Engagement of employees as problem solvers • Lean and 6 sigma philosophies • Downstreaming work • Elevate work to limit of license • Offload tasks to level of skill needed Workforce Sustainability
- 65. Riverside Health Advisors • Thank You • The Challenge • The Talk of Value • C Suite Priorities • Better Conversations • Thank You Agenda
- 66. Riverside Health Advisors June 20, 2018 l 65 Patient Purchaser Health System Surgeon Industry Regulator Payer Value in Healthcare: Healthcare Ecosystem Changing Relationships Cost for one = profit for another and one person’s waste is another’s business Who provides Value? Value to Whom? What is the Patient Willing to Pay for? $3 Trillion Opportunity/Risk
- 67. Riverside Health Advisors Results of Value Creation • As a provider of a good or service • I expect to be rewarded for creating value • Increased market share • Happy customers, referring others • Premium pricing if customer rewards my value proposition • Value creation is not the opposite of volume, but rather increased market share (volume) is the natural consequence.
- 68. Riverside Health Advisors Innovation as the Path to Value Creation • Innovation is the engine of our economy • Process improvement and technology enhancements add value • Better solutions to existing problems • Redefining a problem so that it is amenable to a simplified solution • Providing new methods that are lower cost • Cost as defined by money or disutility or both • Reducing friction in a system, improving flow • Applying existing technology in new ways • Introducing new technology
- 69. Riverside Health Advisors Health System/Vendor Relations • Moving toward a “partnership” based on shared risk • Want to get away from a RFP based on price • Want to be viewed as more than a commodity • We can move the needle on: • Quality • Efficiency • Value
- 70. Riverside Health Advisors Impact of New Technology • Key Questions • What problem (facing the buyer) are we trying to solve? • How is this new technology or solution better than what exists? • Is it incremental or a true leap ahead? • Who (which people) will benefit from the solution? Be specific • Who is willing to pay for it and specifically, out of whose budget? • Operational • Capital • Matched up against the C-suite problem list: • Market share • Margin improvement • Revenue enhancement • Cost reduction • Enhanced throughput • Workforce sustainability • Physician alignment
- 71. Riverside Health Advisors Introducing Innovation: 5 Ts • Talented leaders • Teamwork and understanding team dynamics • Training, teaching and ingraining a new method • Technique and the understanding of workflows and how to apply the new solution • Technology and the secondary impacts of new methods • Obstacles to adoption • Unforeseen events
- 72. Riverside Health Advisors Talent, Teams and Technology Surgeon’s Concerns • Who will use this technology? • Does it improve quality, efficiency, experience? • Is it an evolution or paradigm shifting ? • How do I adopt it? • What do I need to do to prepare my team and myself? • How will my work change? • How does this impact my workflows? • Am I now accountable for a new set of data or new standard?
- 73. Riverside Health Advisors Training, Technique and Adoption: Level of Investment • Pilot program vs. scaled solution • Where and how do I set up a pilot? • How long does it take to assess value and will this technology have evolved? • How is it best introduced? • Who should be trained and where? • How much iteration and customization do we allow? • Should it be standardized?
- 74. Riverside Health Advisors Technology: Level of Investment • Point solution vs. comprehensive offering • Best in class offering—small, focused, nimble • Integrated solution—interoperable, fewer interfaces • Where is this product in its development cycle? • Prototype vs. commercialized • How are new upgrades introduced? • Existing system augment vs. new offering vs. tech giant • Epic, Cerner, Allscripts, Athena…Stryker, ZB, JJ, SN... • Tech start up • Apple, Fitbit, Samsung, Siemens, GE...
- 75. Riverside Health Advisors Technology Revolution: Business Concerns • Whose budget does this come out of? • When do you pull the trigger and dive in? • Speed of change, risk of delay, maturity of technology • Is it solving one of my top concerns? • How do we mesh this from an IT perspective? • Cyber concerns, interoperability, BAA • Financing—what is the business model that makes sense? • SaaS? Lease? Purchase?
- 76. Riverside Health Advisors Future Directions • Payment models and their impact on health systems will continue to define opportunities to differentiate our offerings based on the attributes and the price of our products • As payment models evolve, we need to stay aligned and ensure that we are responding and being rewarded for • improving outcomes • Improving efficiency • Improving work for our teams • Our value only comes from our ability to solve the problems that our customers (providers and their patients) are facing
- 77. Riverside Health Advisors • What we do matters • We improve lives • We relieve pain • We restore motion and function • We return people to work and play • We allow people to enjoy their families and milestone events • The future is bright for orthopedics Thank You for All You Do for Our Patients