- Email: [email protected]
Quality and Value in an Evolving Health Care Landscape
THE HAND SURGERY LANDSCAPE
Quality and Value in an Evolving Health Care Landscape Robin N. Kamal, MD,* Hand Surgery Quality Consortium†
Demonstrating and improving value of care continues to be increasingly important in hand surgery. To prepare for emerging models that transition payment from volume to value, hand surgeons will benefit from a clear understanding of quality, cost, and value. National organizations and both public and private payers increasingly advocate for patient-reported outcome measures for pay for reporting and pay for performance initiatives. These are intended to incentivize providers and health systems to improve patient-centered care while minimizing costs. Appreciating the limitations to using patient-reported outcomes in hand surgery can ensure hand surgery is appropriately assessed in novel payment models. (J Hand Surg Am. 2016;41(7):794e799. Copyright Ó 2016 by the American Society for Surgery of the Hand. All rights reserved.) Key words Hand surgery, quality, quality measure, value, value-based health care.
H
from 1980 to 2010. Americans spend almost double the proportion of the gross domestic product on health care than do other developed countries. Expenditures in the fee-for-service model, in which delivering more services is rewarded, has contributed to this unsustainable cost in United States health.1 Large variations in care combined with a rise in costs have led to initiatives that emphasize value (improving health EALTH CARE COSTS ALMOST DOUBLED
From the *Department of Orthopaedic Surgery, Stanford University, Redwood City, CA. †Hand Surgery Quality Consortium members include: Robin N. Kamal, MD, Jeffrey Yao, MD, and Amy Ladd, MD (Department of Orthopaedic Surgery, Stanford University, Redwood City, CA); Alex H. S. Harris, PhD (Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA); Sanjeev Kakar, MD, MBA (Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN); Phil Blazar, MD (Department of Orthopaedic Surgery, Brigham and Women’s Hospital/Harvard University, Boston, MA); Edward Akelman, MD and Chris Got, MD (Department of Orthopaedic Surgery, Rhode Island Hospital/Brown University, Providence, RI); David Ruch, MD and Marc Richard, MD (Department of Orthopaedic Surgery, Duke University, Durham, NC); and David Ring, MD, PhD (Department of Surgery and Perioperative Care, Dell Medical SchooleThe University of Texas at Austin, Austin, TX). Received for publication May 15, 2016; accepted in revised form May 26, 2016. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Robin N. Kamal, MD, Department of Orthopaedic Surgery, Stanford University, 450 Broadway Street, Pavilion C, 440 Redwood City, CA 94063; e-mail: [email protected]. 0363-5023/16/4107-0010$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2016.05.016
794
r
Ó 2016 ASSH
r
Published by Elsevier, Inc. All rights reserved.
with minimal cost) rather than volume (eg, ordering tests, prescribing medications, and completing procedures). These initiatives are based on the lessons of behavioral economics: Human decisions are affected by context (limited rationality; eg, loss aversion) and altruism (bounded self-interest; eg, people often turn down unfair offers under ultimatum circumstances), and subject to lack of self-control (bounded willpower; eg, even the most successful humans sometimes eat, drink, or spend too much).2 Aligning the interest of all stakeholders in value-based models takes advantage of known behavioral, economic, and psychological principles to improve the value of care. Similar initiatives are under way in many other parts of the world.3,4 A firm understanding of the definitions and influence of quality and value on current and emerging health initiatives allows the hand surgeon to better prepare for these initiatives and help shape them. QUALITY AND VALUE The most common definitions of quality address the infrastructure to provide care (structure), the appropriate provision of care (process), and the ultimate patient-centered outcome (outcome, symptoms, and limitations, for example).5 The Institute of Medicine’s definition of quality is “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are
QUALITY AND VALUE IN EVOLVING HEALTH CARE
consistent with current professional knowledge.”6 Quality measures are constructed to create a working, usable, definition of quality. For instance, calculating the percentage of operative cases with a documented preoperative history and physical helps define and analyze an important process of care. This measurement can be benchmarked by specialty, hospital, region, and nation. Medicare, National Quality Forum, and Agency for Healthcare Research and Quality have developed frameworks to guide measure development. These measures typically undergo a process of evaluation for importance, feasibility, scientific soundness, and usability. When possible, it is important to adjust for comorbidities (risk) to limit unintended consequences from attempts to improve quality. For example, a quality measure evaluating mortality after coronary artery bypass graft would need to account for the comorbidities that have a demonstrated impact on survival to avoid incentivizing the avoidance of sicker patients to boost performance.7 Value in health care is defined as the quality achieved per dollar spent over the entire episode of patient care. Some suggest that value must specifically account for appropriateness of care. For example, it would be inappropriate to inject a trigger finger in perpetuity without offering surgery, even if it resulted in decreased costs compared with surgical trigger finger release. Most would agree that mandating bilateral hand surgery, such as bilateral carpal tunnel surgery, would also be inappropriate. Others suggest that value is defined as outcomes per cost, minimizing the importance of other aspects of quality, including adhering to processes of care, such as a clinical practice guidelines.3 The scope of “outcome” also varies in these frameworks. Outcome can refer to the diseasespecific outcome (improvement in pain and sleep after carpal tunnel release [CTR]) or, more broadly, the patient’s overall general health, not just the specific illness (keeping an elderly patient independent for activities of daily living after thumb arthroplasty).8 Measurement of costs should include all aspects over the continuum of care, from hospitalization to rehabilitation, tests, physicians involved, facilities used, and costs to the patient and society.9 There are multiple ways to calculate costs. Most often, cost is underestimated by calculating only payer charges or provider reimbursement, without understanding the actual internal costs incurred during care, which is a better representation of the actual resources consumed. Often cost calculation includes only the acute episode of treatment (operating room and facility fee, for example) without appreciating the costs of follow-up visits, physical or occupational therapy, preoperative J Hand Surg Am.
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and postoperative testing, or downstream complications and/or reoperations. Some have begun using time-driven activity-based costing, a method of calculating costs over the continuum of care that transcends departments and isolated events. Instead, cost is allocated over the whole episode of care and can demonstrate overall cost savings despite, for example, increased costs during surgery.10 A potential example would be demonstrating overall cost savings through shorter operating room time, quicker recovery, and less use of rehabilitation services for a patient who had a more costly arthroscopic procedure. Traditional calculations also ignore other costs important to the patient, such as indirect costs (having to hire a babysitter, payment for parking, and missed work) or intangible costs (increased family burden). Whereas the ultimate goal of value-based health care is to improve quality of care while decreasing costs, overall cost to the patient and patients’ understanding of cost have largely gone unstudied.11 WHY DEFINING QUALITY IN HAND SURGERY IS IMPORTANT Recent efforts by national organizations such as the American Academy of Orthopaedic Surgeons focus on defining and measuring quality and providing costefficient care. Indeed, the cost of hip and knee arthroplasty to Medicare, for example, has led to the implementation of outcome quality measures evaluating total joint arthroplasty, the first orthopedic subspecialty scrutinized by payers nationally. As such, the national movement toward using patient-reported outcome measures (PROMs) to define quality has been adopted by hip and knee surgeons. As value initiatives move forward, it is important to recognize some key areas that make hand surgery unique. First, hand surgery is a relatively heterogeneous field in terms of pathology and procedures. For example, hand surgery includes general, orthopedic, and plastic surgeons who treat patients of all ages and all tissues from the shoulder to the fingertips. As such, there is significant variation in the types of procedures completed: to prevent worsening of symptoms (eg, CTR release for severe carpal tunnel syndrome [CTS]), for cosmesis or discomfort (eg, ganglion excision), for trauma (eg, finger replantation), for pain (eg, basal joint arthroplasty or trigger finger release), or for function (eg, free-functioning gracilis in brachial plexopathy or tendon transfers). Payers continue to ask for “cross-cutting” PROMs that could be applied for quality reporting. There are benefits (feasibility of data collection and reporting, for example) to using one measure consistently for all r
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illnesses. However, one “cross-cutting” instrument will not be able to measure a clinically important change in all treatments, and it runs the risk of marginalizing the effects of interventions. This could be detrimental in a value-based system that uses magnitude of improvement for payment. It seems intuitive that a validated disease or region-specific measure would better capture the benefits of hand surgery interventions because it would demonstrate the greatest effect size (magnitude of impact). Instead of emphasizing the precision of various sophisticated PROMs, our initial efforts should focus on balancing implementation (How do I administer a PROM efficiently in all practice types?), adequacy of measurement (a practical and adequately responsive PROM), and actionability (How do I use information I am gathering to improve care?). Second, patient-reported outcomes used as performance measures (to judge the quality of hand surgery, such as PROM-performance measurement) are limited in use if not thoughtfully employed. There is a strong influence of psychosocial factors on PROMs that is prominent in hand surgery.12e14 It can be difficult to find the “signal” (the beneficial effects of an alteration in pathophysiology) in the “noise” (the massive variation in PROM scores owing to mindset and circumstances). Even when such a signal is found, it is difficult to consider a treatment to be a success when PROMs continue to demonstrate substantial symptoms and limitations.12 Patient-rated outcome measures are almost certainly the best measure of quality in the management of conditions that cause subjective symptoms that effect quality of life and for which treatment is elective and preference-sensitive (eg, arthritis or Dupuytren disease). However, objective measures of pathophysiology might be preferred when surgery to modify the course of the illness is merited at some point regardless of symptoms and limitations (eg, open fracture). For example, a patient with less effective coping strategies and greater symptoms of depression may have substantial residual symptoms and limitations measured by a PROM after successful CTR.13 On the other hand, platelet-rich plasma may improve a PROM score in a patient with an enthesopathy, but no more than would a saline injection.15 Vital to developing PROM performance measurements is establishing risk adjustments based on highlevel evidence. For example, a patient with less effective coping strategies and greater symptoms of depression may have substantial residual symptoms measured by a PROM after successful trigger finger release.16 As we start to measure PROMs, we should be mindful of these factors and build risk-stratification J Hand Surg Am.
models that account for them. Modeling may find that management of psychosocial factors in conjunction with hand pathophysiology may benefit patients to a greater magnitude than would managing hand pathophysiology alone. Third, the emphasis should be on defining and studying quality.17 Minimizing low-quality processes can lead to increased value without focusing efforts on cutting costs. Medicare analyses of quality measures demonstrate that variations in quality have more impact on value than do variations in cost.18 Quality measures can address areas of care that lead to reduced costs, such as appropriate use of diagnostic tests. The first step, however, is defining quality and then devising measures that can inform efforts to limit low-quality interventions. SHIFTING TO ALTERNATIVE PAYMENT MODELS Unsustainable costs providing a questionable quality of care are motivating a shift toward alternative payment models (APMs). For example, the Institute of Medicine’s report, Crossing the Quality Chasm, highlighted opportunities for improvement in our current system by addressing fragmented care, ineffective communication, and disparate incentives of stakeholders.6 Alternative payment models attempt to align stakeholder incentives to provide high-value care by shifting potential risks and benefits to providers and hospitals. Medicare expects that at least 50% of payments will be through APMs by 2018.2 Private payers are starting to follow the lead of these federal initiatives. The transition to a valuebased health care system includes: (1) an infrastructure to collect, share, and analyze data; (2) national benchmarks for quality and cost; and (3) aligned incentives of all stakeholders. Meaningful use was introduced by the United States government in 2009 and mandated use of a certified electronic health record (EHR) to create an infrastructure for better communication of health information. The expectation is that EHRs will make it easier to track quality data, minimize reporter burden on quality measures, and improve value through better care coordination and patient engagement.19 Medicare is currently incentivizing quality reporting in preparation for reimbursement based on specific benchmarks. At the provider level, Medicare implemented the Physician Quality Reporting System (PQRS)20 and the Value Modifier (VM).18 For PQRS, providers submit quality measures on their Medicare patients to avoid an automatic negative payment adjustment on their reimbursements 2 calendar years later. There are no quality measures within the PQRS r
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measure set that specifically apply to the practice of hand surgery, which leaves hand surgeons to report on generic measures such as medication reconciliation and smoking cessation, for example. The VM is a budget-neutral, Medicare-directed program that collects cost data from the provision of services to Medicare patients. Cost data are then combined with quality data to calculate the value of a provider’s care. Provider data are both risk- and specialty-stratified, compared with historical benchmark data, and then categorized as low, average, or high quality and cost. Providers are incentivized to improve continuously via negative and positive payment adjustments that are compared with national benchmarks. In 2015, Congress passed the Medicare Access and CHIP Reauthorization Act of 2015 to reform the Medicare payment system to providers.21 In 2019, providers will have the options of participating in the Merit-Based Incentive Payment System or an APM. The Merit-Based Incentive Payment System is a combination of meaningful use, PQRS, and VM applied to a fee-for-service model. The physician is scored from 0 to 100 based on reporting quality measures (50%, similar to PQRS), resource use (10%, similar to VM), use of an EHR (25%, similar to meaningful use), and quality improvement activities (15%). Alternative payment models shift the financial risks of patient care to providers and health systems to incentivize high-value care. Some of these models have already been tested by Medicare and private payers. For example, the Bundled Payments for Care Improvement is a Medicare pilot program that has trialed bundled payments to hospitals and posteacute care facilities since 2012. From 2019 to 2024, Medicare will subsidize practices that join APMs. The quality measures are the same as in the MeritBased Incentive Payment System. Examples of APMs are bundled payments, patient-centered medical homes, and accountable care organizations. In a bundled payment there is a single payment to a group of providers for provision of an acute care episode.22 Medicare is testing bundled payments with the Comprehensive Care for Joint Replacement Model, which is currently bundling payments for total joint arthroplasty in 67 metropolitan areas.23 If this model were applied to CTR, for example, there would be one payment to the providers of surgery and postoperative management. This would provide a disincentive for expenses that may not add to quality, such as postoperative use of an orthosis and formal hand therapy. Patient-centered medical homes are a redesigned approach at primary care. They are made of a care team J Hand Surg Am.
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that creates a seamless transition and coordinates care among all providers and care sites. Care coordinators ensure that services address patient preferences, add quality, avoid redundancy, and encourage patients to be actively engaged in their health. Accountable care organizations are groups of providers, hospitals, and post-acute providers that contract with payers to provide comprehensive, coordinated care for a defined population of patients. Quality and cost data are measured and all providers share responsibility (through bonuses and penalties) for the value of care provided. The underlying theme of all APMs is that by aligning incentives between payers and providers, improving communication among providers, and focusing efforts on quality and value, providers and payers can share in potential profits (and losses). VALUE-BASED PAYMENTS IN HAND SURGERY Because these changes are starting to spread to private payers, defining and measuring quality is important in hand surgery practices regardless of payer mix. As hand surgeons prepare for value-based health care, there are a number of thoughtful ways to rethink our care. First, how do we balance adopting innovative, profit-sharing payment models without curbing our research efforts? The current fee-for-service model incentivizes doing more—more tests, more injections, more surgery, and more physical and occupational therapy. Owning our own ambulatory surgery centers, diagnostic imaging, therapy centers, and implant companies may amplify the incentives to do more. The new system will encourage treatment with the simplest, safest, most resourceful treatment and require evidence of added value from new treatments. Freedom to do more, and allowing for practice variations, can lead to evidence that informs future highlevel studies and better patient outcomes. For example, low-level studies on fixing clavicle fractures led to a randomized controlled trial showing superior outcomes after fixation in certain patients.24 The emerging health care model may not allow for as much practice variation. Our reliance on research grants to support variations in care for unstudied populations (high-functioning geriatric patients, for example) or new implants (total wrist replacements), as opposed to following rigid clinical care pathways, will likely grow. As such, grant-funding agencies or implant manufacturers may be burdened with supporting clinical questions that were previously supported by the fee-for-service model. Second, how do we leverage a value-based model to benefit all stakeholders? Instead of incentivizing doing r
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more, APMs incentivize doing enough—judicious use of resources that optimize quality (high value). In APMs, variations in care represent opportunities. In the current model, there is no incentive to reconsider the biases and habits (an uncomfortable exercise owing to commitment bias) that create unhelpful variations in care among surgeons. In an APM, research and quality improvement endeavors that identify the highest value options have the potential to increase revenue—a powerful incentive for surgeons to be humble and reflective about their care. These models provide an incentive to adopt best practices, to learn from one another, and to value feedback and data. Third, value-based incentives motivate research and quality improvement. For example, using a clinical prediction rule based on symptoms and signs (eg, the 6-item CTS symptoms scale) to diagnose CTS instead of routine electrodiagnostic testing might lead to increased revenue in a bundled payment system with no effect on quality. On the other hand, this approach could decrease revenue if the absence of an objective measure of disease severity leads to repeat surgery in patients who are not satisfied after CTR. We need to consider the options and study them to determine which provide higher value. Engaging patients in research design and the definition of success can help ensure that the results of patient-centered outcomes research are more readily translated into clinical practice. Fourth, hand surgery as a specialty takes pride in acknowledging the art of medicine. Incentives based on quality benchmarks risk devaluing the physicianepatient relationship and interfering with patient-centered care. On the other hand, value-based incentives seem to raise opportunities for improvement in communication strategies, increased patient engagement, and comprehensive programs that address psychosocial factors. The association between provider empathy and patient satisfaction and the predominant influence of stress, distress, and less effective coping strategies (resilience) point us to opportunities for increasing value via attention to the nontechnical aspects of care—a key component of the art of medicine. Value frameworks can acknowledge and reward efforts to address these nontechnical aspects of care (eg, patient education and home-based therapy programs). The transition to value-based health incentives may bring dramatic changes to the day-to-day practice of medicine, clinical and translational research, and the innovation and implementation of new treatments. Models that fit specific disease types (eg, bundled payments for outpatient discretionary hand surgery) have the potential to improve value by J Hand Surg Am.
improving patient-reported outcomes while diminishing costly and unnecessary variations in care. The key at this stage is to develop useful definitions and measures of quality that reflect value accurately in hand surgery. REFERENCES 1. Laugesen MJ, Glied SA. Higher fees paid to US physicians drive higher spending for physician services compared to other countries. Health Aff (Millwood). 2011;30(9):1647e1656. 2. Khullar D, Chokshi DA, Kocher R, et al. Behavioral economics and physician compensation —promise and challenges. N Engl J Med. 2015;372(24):2281e2283. 3. Wei DH, Hawker GA, Jevsevar DS, Bozic KJ. Improving value in musculoskeletal care delivery: AOA critical issues. J Bone Joint Surg Am. 2015;97(9):769e774. 4. Briggs AM, Jordan JE, Speerin R, et al. Models of care for musculoskeletal health: a cross-sectional qualitative study of Australian stakeholders’ perspectives on relevance and standardised evaluation. BMC Health Serv Res. 2015;15:509. 5. Kamal RN, Ring D, Akelman E, et al. Quality measures in upper limb surgery. J Bone Joint Surg Am. 2016;98(6):505e510. 6. Crossing the quality chasm: the IOM Health Care Quality Initiative— Institute of Medicine. http://iom.nationalacademies.org/Global/News %20Announcements/Crossing-the-Quality-Chasm-The-IOM-HealthCare-Quality-Initiative.aspx. Accessed July 17, 2015. 7. Werner RM, Asch DA, Polsky D. Racial profiling: the unintended consequences of coronary artery bypass graft report cards. Circulation. 2005;111(10):1257e1263. 8. Porter ME. A strategy for health care reform—toward a value-based system. N Engl J Med. 2009;361(2):109e112. 9. Porter ME, Pabo EA, Lee TH. Redesigning primary care: a strategic vision to improve value by organizing around patients’ needs. Health Aff Proj Hope. 2013;32(3):516e525. 10. Sabharwal S, Carter AW, Rashid A, Darzi A, Reilly P, Gupte CM. Cost analysis of the surgical treatment of fractures of the proximal humerus: an evaluation of the determinants of cost and comparison of the institutional cost of treatment with the national tariff. Bone Joint J. 2016;98-B(2):249e259. 11. Irwin B, Kimmick G, Altomare I, et al. Patient experience and attitudes toward addressing the cost of breast cancer care. The Oncologist. 2014;19(11):1135e1140. 12. London DA, Stepan JG, Boyer MI, Calfee RP. The impact of depression and pain catastrophization on initial presentation and treatment outcomes for atraumatic hand conditions. J Bone Joint Surg Am. 2014;96(10):806e814. 13. Das De S, Vranceanu A-M, Ring DC. Contribution of kinesophobia and catastrophic thinking to upper-extremity-specific disability. J Bone Joint Surg Am. 2013;95(1):76e81. 14. Vranceanu A-M, Jupiter JB, Mudgal CS, Ring D. Predictors of pain intensity and disability after minor hand surgery. J Hand Surg. 2010;35(6):956e960. 15. Krogh TP, Fredberg U, Stengaard-Pedersen K, Christensen R, Jensen P, Ellingsen T. Treatment of lateral epicondylitis with platelet-rich plasma, glucocorticoid, or saline: a randomized, double-blind, placebo-controlled trial. Am J Sports Med. 2013;41(3):625e635. 16. Julka A, Vranceanu A-M, Shah AS, Peters F, Ring D. Predictors of pain during and the day after corticosteroid injection for idiopathic trigger finger. J Hand Surg Am. 2012;37(2):237e242. 17. Kamal RN, Kakar S, Ruch D, et al. Quality measurement: a primer for hand surgeons. J Hand Surg. 2016;41(5):645e651. 18. Value-based payment modifier. Centers for Medicare & Medicaid Services. https://www.cms.gov/medicare/medicare-fee-for-servicepayment/physicianfeedbackprogram/valuebasedpaymentmodifier. html. Accessed May 3, 2016.
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22. Clair AJ, Evangelista PJ, Lajam CM, Slover JD, Bosco JA, Iorio R. Cost analysis of total joint arthroplasty readmissions in a bundled payment care improvement initiative [e-pub ahead of print February 24, 2016]. J Arthroplasty. http://dx.doi.org/10.1016/j.arth.2016.02.029. 23. Comprehensive care for joint replacement model. Center for Medicare & Medicaid Innovation. https://innovation.cms.gov/initiatives/ cjr. Accessed May 3, 2016. 24. Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures: a multicenter, randomized clinical trial. J Bone Joint Surg Am. 2007;89(1):1e10.
19. Electronic Health Records (EHR) Incentive Programs. Centers for Medicare & Medicaid Services. https://www.cms.gov/Regulations-andGuidance/Legislation/EHRIncentivePrograms/index.html. Accessed May 3, 2016. 20. Medicare C for, Baltimore MS 7500 SB, Usa M. PQRS Overview. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/index.html. Accessed July 17, 2015. 21. MACRA: MIPS & APMs. Centers for Medicare & Medicaid Services. https://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/Value-Based-Programs/MACRA-MIPSand-APMs/MACRA-MIPS-and-APMs.html. Accessed May 3, 2016.
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Vol. 41, July 2016
Quality and Value in an Evolving Health Care Landscape Robin N. Kamal, MD,* Hand Surgery Quality Consortium†
Demonstrating and improving value of care continues to be increasingly important in hand surgery. To prepare for emerging models that transition payment from volume to value, hand surgeons will benefit from a clear understanding of quality, cost, and value. National organizations and both public and private payers increasingly advocate for patient-reported outcome measures for pay for reporting and pay for performance initiatives. These are intended to incentivize providers and health systems to improve patient-centered care while minimizing costs. Appreciating the limitations to using patient-reported outcomes in hand surgery can ensure hand surgery is appropriately assessed in novel payment models. (J Hand Surg Am. 2016;41(7):794e799. Copyright Ó 2016 by the American Society for Surgery of the Hand. All rights reserved.) Key words Hand surgery, quality, quality measure, value, value-based health care.
H
from 1980 to 2010. Americans spend almost double the proportion of the gross domestic product on health care than do other developed countries. Expenditures in the fee-for-service model, in which delivering more services is rewarded, has contributed to this unsustainable cost in United States health.1 Large variations in care combined with a rise in costs have led to initiatives that emphasize value (improving health EALTH CARE COSTS ALMOST DOUBLED
From the *Department of Orthopaedic Surgery, Stanford University, Redwood City, CA. †Hand Surgery Quality Consortium members include: Robin N. Kamal, MD, Jeffrey Yao, MD, and Amy Ladd, MD (Department of Orthopaedic Surgery, Stanford University, Redwood City, CA); Alex H. S. Harris, PhD (Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA); Sanjeev Kakar, MD, MBA (Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN); Phil Blazar, MD (Department of Orthopaedic Surgery, Brigham and Women’s Hospital/Harvard University, Boston, MA); Edward Akelman, MD and Chris Got, MD (Department of Orthopaedic Surgery, Rhode Island Hospital/Brown University, Providence, RI); David Ruch, MD and Marc Richard, MD (Department of Orthopaedic Surgery, Duke University, Durham, NC); and David Ring, MD, PhD (Department of Surgery and Perioperative Care, Dell Medical SchooleThe University of Texas at Austin, Austin, TX). Received for publication May 15, 2016; accepted in revised form May 26, 2016. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Robin N. Kamal, MD, Department of Orthopaedic Surgery, Stanford University, 450 Broadway Street, Pavilion C, 440 Redwood City, CA 94063; e-mail: [email protected]. 0363-5023/16/4107-0010$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2016.05.016
794
r
Ó 2016 ASSH
r
Published by Elsevier, Inc. All rights reserved.
with minimal cost) rather than volume (eg, ordering tests, prescribing medications, and completing procedures). These initiatives are based on the lessons of behavioral economics: Human decisions are affected by context (limited rationality; eg, loss aversion) and altruism (bounded self-interest; eg, people often turn down unfair offers under ultimatum circumstances), and subject to lack of self-control (bounded willpower; eg, even the most successful humans sometimes eat, drink, or spend too much).2 Aligning the interest of all stakeholders in value-based models takes advantage of known behavioral, economic, and psychological principles to improve the value of care. Similar initiatives are under way in many other parts of the world.3,4 A firm understanding of the definitions and influence of quality and value on current and emerging health initiatives allows the hand surgeon to better prepare for these initiatives and help shape them. QUALITY AND VALUE The most common definitions of quality address the infrastructure to provide care (structure), the appropriate provision of care (process), and the ultimate patient-centered outcome (outcome, symptoms, and limitations, for example).5 The Institute of Medicine’s definition of quality is “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are
QUALITY AND VALUE IN EVOLVING HEALTH CARE
consistent with current professional knowledge.”6 Quality measures are constructed to create a working, usable, definition of quality. For instance, calculating the percentage of operative cases with a documented preoperative history and physical helps define and analyze an important process of care. This measurement can be benchmarked by specialty, hospital, region, and nation. Medicare, National Quality Forum, and Agency for Healthcare Research and Quality have developed frameworks to guide measure development. These measures typically undergo a process of evaluation for importance, feasibility, scientific soundness, and usability. When possible, it is important to adjust for comorbidities (risk) to limit unintended consequences from attempts to improve quality. For example, a quality measure evaluating mortality after coronary artery bypass graft would need to account for the comorbidities that have a demonstrated impact on survival to avoid incentivizing the avoidance of sicker patients to boost performance.7 Value in health care is defined as the quality achieved per dollar spent over the entire episode of patient care. Some suggest that value must specifically account for appropriateness of care. For example, it would be inappropriate to inject a trigger finger in perpetuity without offering surgery, even if it resulted in decreased costs compared with surgical trigger finger release. Most would agree that mandating bilateral hand surgery, such as bilateral carpal tunnel surgery, would also be inappropriate. Others suggest that value is defined as outcomes per cost, minimizing the importance of other aspects of quality, including adhering to processes of care, such as a clinical practice guidelines.3 The scope of “outcome” also varies in these frameworks. Outcome can refer to the diseasespecific outcome (improvement in pain and sleep after carpal tunnel release [CTR]) or, more broadly, the patient’s overall general health, not just the specific illness (keeping an elderly patient independent for activities of daily living after thumb arthroplasty).8 Measurement of costs should include all aspects over the continuum of care, from hospitalization to rehabilitation, tests, physicians involved, facilities used, and costs to the patient and society.9 There are multiple ways to calculate costs. Most often, cost is underestimated by calculating only payer charges or provider reimbursement, without understanding the actual internal costs incurred during care, which is a better representation of the actual resources consumed. Often cost calculation includes only the acute episode of treatment (operating room and facility fee, for example) without appreciating the costs of follow-up visits, physical or occupational therapy, preoperative J Hand Surg Am.
795
and postoperative testing, or downstream complications and/or reoperations. Some have begun using time-driven activity-based costing, a method of calculating costs over the continuum of care that transcends departments and isolated events. Instead, cost is allocated over the whole episode of care and can demonstrate overall cost savings despite, for example, increased costs during surgery.10 A potential example would be demonstrating overall cost savings through shorter operating room time, quicker recovery, and less use of rehabilitation services for a patient who had a more costly arthroscopic procedure. Traditional calculations also ignore other costs important to the patient, such as indirect costs (having to hire a babysitter, payment for parking, and missed work) or intangible costs (increased family burden). Whereas the ultimate goal of value-based health care is to improve quality of care while decreasing costs, overall cost to the patient and patients’ understanding of cost have largely gone unstudied.11 WHY DEFINING QUALITY IN HAND SURGERY IS IMPORTANT Recent efforts by national organizations such as the American Academy of Orthopaedic Surgeons focus on defining and measuring quality and providing costefficient care. Indeed, the cost of hip and knee arthroplasty to Medicare, for example, has led to the implementation of outcome quality measures evaluating total joint arthroplasty, the first orthopedic subspecialty scrutinized by payers nationally. As such, the national movement toward using patient-reported outcome measures (PROMs) to define quality has been adopted by hip and knee surgeons. As value initiatives move forward, it is important to recognize some key areas that make hand surgery unique. First, hand surgery is a relatively heterogeneous field in terms of pathology and procedures. For example, hand surgery includes general, orthopedic, and plastic surgeons who treat patients of all ages and all tissues from the shoulder to the fingertips. As such, there is significant variation in the types of procedures completed: to prevent worsening of symptoms (eg, CTR release for severe carpal tunnel syndrome [CTS]), for cosmesis or discomfort (eg, ganglion excision), for trauma (eg, finger replantation), for pain (eg, basal joint arthroplasty or trigger finger release), or for function (eg, free-functioning gracilis in brachial plexopathy or tendon transfers). Payers continue to ask for “cross-cutting” PROMs that could be applied for quality reporting. There are benefits (feasibility of data collection and reporting, for example) to using one measure consistently for all r
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illnesses. However, one “cross-cutting” instrument will not be able to measure a clinically important change in all treatments, and it runs the risk of marginalizing the effects of interventions. This could be detrimental in a value-based system that uses magnitude of improvement for payment. It seems intuitive that a validated disease or region-specific measure would better capture the benefits of hand surgery interventions because it would demonstrate the greatest effect size (magnitude of impact). Instead of emphasizing the precision of various sophisticated PROMs, our initial efforts should focus on balancing implementation (How do I administer a PROM efficiently in all practice types?), adequacy of measurement (a practical and adequately responsive PROM), and actionability (How do I use information I am gathering to improve care?). Second, patient-reported outcomes used as performance measures (to judge the quality of hand surgery, such as PROM-performance measurement) are limited in use if not thoughtfully employed. There is a strong influence of psychosocial factors on PROMs that is prominent in hand surgery.12e14 It can be difficult to find the “signal” (the beneficial effects of an alteration in pathophysiology) in the “noise” (the massive variation in PROM scores owing to mindset and circumstances). Even when such a signal is found, it is difficult to consider a treatment to be a success when PROMs continue to demonstrate substantial symptoms and limitations.12 Patient-rated outcome measures are almost certainly the best measure of quality in the management of conditions that cause subjective symptoms that effect quality of life and for which treatment is elective and preference-sensitive (eg, arthritis or Dupuytren disease). However, objective measures of pathophysiology might be preferred when surgery to modify the course of the illness is merited at some point regardless of symptoms and limitations (eg, open fracture). For example, a patient with less effective coping strategies and greater symptoms of depression may have substantial residual symptoms and limitations measured by a PROM after successful CTR.13 On the other hand, platelet-rich plasma may improve a PROM score in a patient with an enthesopathy, but no more than would a saline injection.15 Vital to developing PROM performance measurements is establishing risk adjustments based on highlevel evidence. For example, a patient with less effective coping strategies and greater symptoms of depression may have substantial residual symptoms measured by a PROM after successful trigger finger release.16 As we start to measure PROMs, we should be mindful of these factors and build risk-stratification J Hand Surg Am.
models that account for them. Modeling may find that management of psychosocial factors in conjunction with hand pathophysiology may benefit patients to a greater magnitude than would managing hand pathophysiology alone. Third, the emphasis should be on defining and studying quality.17 Minimizing low-quality processes can lead to increased value without focusing efforts on cutting costs. Medicare analyses of quality measures demonstrate that variations in quality have more impact on value than do variations in cost.18 Quality measures can address areas of care that lead to reduced costs, such as appropriate use of diagnostic tests. The first step, however, is defining quality and then devising measures that can inform efforts to limit low-quality interventions. SHIFTING TO ALTERNATIVE PAYMENT MODELS Unsustainable costs providing a questionable quality of care are motivating a shift toward alternative payment models (APMs). For example, the Institute of Medicine’s report, Crossing the Quality Chasm, highlighted opportunities for improvement in our current system by addressing fragmented care, ineffective communication, and disparate incentives of stakeholders.6 Alternative payment models attempt to align stakeholder incentives to provide high-value care by shifting potential risks and benefits to providers and hospitals. Medicare expects that at least 50% of payments will be through APMs by 2018.2 Private payers are starting to follow the lead of these federal initiatives. The transition to a valuebased health care system includes: (1) an infrastructure to collect, share, and analyze data; (2) national benchmarks for quality and cost; and (3) aligned incentives of all stakeholders. Meaningful use was introduced by the United States government in 2009 and mandated use of a certified electronic health record (EHR) to create an infrastructure for better communication of health information. The expectation is that EHRs will make it easier to track quality data, minimize reporter burden on quality measures, and improve value through better care coordination and patient engagement.19 Medicare is currently incentivizing quality reporting in preparation for reimbursement based on specific benchmarks. At the provider level, Medicare implemented the Physician Quality Reporting System (PQRS)20 and the Value Modifier (VM).18 For PQRS, providers submit quality measures on their Medicare patients to avoid an automatic negative payment adjustment on their reimbursements 2 calendar years later. There are no quality measures within the PQRS r
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measure set that specifically apply to the practice of hand surgery, which leaves hand surgeons to report on generic measures such as medication reconciliation and smoking cessation, for example. The VM is a budget-neutral, Medicare-directed program that collects cost data from the provision of services to Medicare patients. Cost data are then combined with quality data to calculate the value of a provider’s care. Provider data are both risk- and specialty-stratified, compared with historical benchmark data, and then categorized as low, average, or high quality and cost. Providers are incentivized to improve continuously via negative and positive payment adjustments that are compared with national benchmarks. In 2015, Congress passed the Medicare Access and CHIP Reauthorization Act of 2015 to reform the Medicare payment system to providers.21 In 2019, providers will have the options of participating in the Merit-Based Incentive Payment System or an APM. The Merit-Based Incentive Payment System is a combination of meaningful use, PQRS, and VM applied to a fee-for-service model. The physician is scored from 0 to 100 based on reporting quality measures (50%, similar to PQRS), resource use (10%, similar to VM), use of an EHR (25%, similar to meaningful use), and quality improvement activities (15%). Alternative payment models shift the financial risks of patient care to providers and health systems to incentivize high-value care. Some of these models have already been tested by Medicare and private payers. For example, the Bundled Payments for Care Improvement is a Medicare pilot program that has trialed bundled payments to hospitals and posteacute care facilities since 2012. From 2019 to 2024, Medicare will subsidize practices that join APMs. The quality measures are the same as in the MeritBased Incentive Payment System. Examples of APMs are bundled payments, patient-centered medical homes, and accountable care organizations. In a bundled payment there is a single payment to a group of providers for provision of an acute care episode.22 Medicare is testing bundled payments with the Comprehensive Care for Joint Replacement Model, which is currently bundling payments for total joint arthroplasty in 67 metropolitan areas.23 If this model were applied to CTR, for example, there would be one payment to the providers of surgery and postoperative management. This would provide a disincentive for expenses that may not add to quality, such as postoperative use of an orthosis and formal hand therapy. Patient-centered medical homes are a redesigned approach at primary care. They are made of a care team J Hand Surg Am.
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that creates a seamless transition and coordinates care among all providers and care sites. Care coordinators ensure that services address patient preferences, add quality, avoid redundancy, and encourage patients to be actively engaged in their health. Accountable care organizations are groups of providers, hospitals, and post-acute providers that contract with payers to provide comprehensive, coordinated care for a defined population of patients. Quality and cost data are measured and all providers share responsibility (through bonuses and penalties) for the value of care provided. The underlying theme of all APMs is that by aligning incentives between payers and providers, improving communication among providers, and focusing efforts on quality and value, providers and payers can share in potential profits (and losses). VALUE-BASED PAYMENTS IN HAND SURGERY Because these changes are starting to spread to private payers, defining and measuring quality is important in hand surgery practices regardless of payer mix. As hand surgeons prepare for value-based health care, there are a number of thoughtful ways to rethink our care. First, how do we balance adopting innovative, profit-sharing payment models without curbing our research efforts? The current fee-for-service model incentivizes doing more—more tests, more injections, more surgery, and more physical and occupational therapy. Owning our own ambulatory surgery centers, diagnostic imaging, therapy centers, and implant companies may amplify the incentives to do more. The new system will encourage treatment with the simplest, safest, most resourceful treatment and require evidence of added value from new treatments. Freedom to do more, and allowing for practice variations, can lead to evidence that informs future highlevel studies and better patient outcomes. For example, low-level studies on fixing clavicle fractures led to a randomized controlled trial showing superior outcomes after fixation in certain patients.24 The emerging health care model may not allow for as much practice variation. Our reliance on research grants to support variations in care for unstudied populations (high-functioning geriatric patients, for example) or new implants (total wrist replacements), as opposed to following rigid clinical care pathways, will likely grow. As such, grant-funding agencies or implant manufacturers may be burdened with supporting clinical questions that were previously supported by the fee-for-service model. Second, how do we leverage a value-based model to benefit all stakeholders? Instead of incentivizing doing r
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more, APMs incentivize doing enough—judicious use of resources that optimize quality (high value). In APMs, variations in care represent opportunities. In the current model, there is no incentive to reconsider the biases and habits (an uncomfortable exercise owing to commitment bias) that create unhelpful variations in care among surgeons. In an APM, research and quality improvement endeavors that identify the highest value options have the potential to increase revenue—a powerful incentive for surgeons to be humble and reflective about their care. These models provide an incentive to adopt best practices, to learn from one another, and to value feedback and data. Third, value-based incentives motivate research and quality improvement. For example, using a clinical prediction rule based on symptoms and signs (eg, the 6-item CTS symptoms scale) to diagnose CTS instead of routine electrodiagnostic testing might lead to increased revenue in a bundled payment system with no effect on quality. On the other hand, this approach could decrease revenue if the absence of an objective measure of disease severity leads to repeat surgery in patients who are not satisfied after CTR. We need to consider the options and study them to determine which provide higher value. Engaging patients in research design and the definition of success can help ensure that the results of patient-centered outcomes research are more readily translated into clinical practice. Fourth, hand surgery as a specialty takes pride in acknowledging the art of medicine. Incentives based on quality benchmarks risk devaluing the physicianepatient relationship and interfering with patient-centered care. On the other hand, value-based incentives seem to raise opportunities for improvement in communication strategies, increased patient engagement, and comprehensive programs that address psychosocial factors. The association between provider empathy and patient satisfaction and the predominant influence of stress, distress, and less effective coping strategies (resilience) point us to opportunities for increasing value via attention to the nontechnical aspects of care—a key component of the art of medicine. Value frameworks can acknowledge and reward efforts to address these nontechnical aspects of care (eg, patient education and home-based therapy programs). The transition to value-based health incentives may bring dramatic changes to the day-to-day practice of medicine, clinical and translational research, and the innovation and implementation of new treatments. Models that fit specific disease types (eg, bundled payments for outpatient discretionary hand surgery) have the potential to improve value by J Hand Surg Am.
improving patient-reported outcomes while diminishing costly and unnecessary variations in care. The key at this stage is to develop useful definitions and measures of quality that reflect value accurately in hand surgery. REFERENCES 1. Laugesen MJ, Glied SA. Higher fees paid to US physicians drive higher spending for physician services compared to other countries. Health Aff (Millwood). 2011;30(9):1647e1656. 2. Khullar D, Chokshi DA, Kocher R, et al. Behavioral economics and physician compensation —promise and challenges. N Engl J Med. 2015;372(24):2281e2283. 3. Wei DH, Hawker GA, Jevsevar DS, Bozic KJ. Improving value in musculoskeletal care delivery: AOA critical issues. J Bone Joint Surg Am. 2015;97(9):769e774. 4. Briggs AM, Jordan JE, Speerin R, et al. Models of care for musculoskeletal health: a cross-sectional qualitative study of Australian stakeholders’ perspectives on relevance and standardised evaluation. BMC Health Serv Res. 2015;15:509. 5. Kamal RN, Ring D, Akelman E, et al. Quality measures in upper limb surgery. J Bone Joint Surg Am. 2016;98(6):505e510. 6. Crossing the quality chasm: the IOM Health Care Quality Initiative— Institute of Medicine. http://iom.nationalacademies.org/Global/News %20Announcements/Crossing-the-Quality-Chasm-The-IOM-HealthCare-Quality-Initiative.aspx. Accessed July 17, 2015. 7. Werner RM, Asch DA, Polsky D. Racial profiling: the unintended consequences of coronary artery bypass graft report cards. Circulation. 2005;111(10):1257e1263. 8. Porter ME. A strategy for health care reform—toward a value-based system. N Engl J Med. 2009;361(2):109e112. 9. Porter ME, Pabo EA, Lee TH. Redesigning primary care: a strategic vision to improve value by organizing around patients’ needs. Health Aff Proj Hope. 2013;32(3):516e525. 10. Sabharwal S, Carter AW, Rashid A, Darzi A, Reilly P, Gupte CM. Cost analysis of the surgical treatment of fractures of the proximal humerus: an evaluation of the determinants of cost and comparison of the institutional cost of treatment with the national tariff. Bone Joint J. 2016;98-B(2):249e259. 11. Irwin B, Kimmick G, Altomare I, et al. Patient experience and attitudes toward addressing the cost of breast cancer care. The Oncologist. 2014;19(11):1135e1140. 12. London DA, Stepan JG, Boyer MI, Calfee RP. The impact of depression and pain catastrophization on initial presentation and treatment outcomes for atraumatic hand conditions. J Bone Joint Surg Am. 2014;96(10):806e814. 13. Das De S, Vranceanu A-M, Ring DC. Contribution of kinesophobia and catastrophic thinking to upper-extremity-specific disability. J Bone Joint Surg Am. 2013;95(1):76e81. 14. Vranceanu A-M, Jupiter JB, Mudgal CS, Ring D. Predictors of pain intensity and disability after minor hand surgery. J Hand Surg. 2010;35(6):956e960. 15. Krogh TP, Fredberg U, Stengaard-Pedersen K, Christensen R, Jensen P, Ellingsen T. Treatment of lateral epicondylitis with platelet-rich plasma, glucocorticoid, or saline: a randomized, double-blind, placebo-controlled trial. Am J Sports Med. 2013;41(3):625e635. 16. Julka A, Vranceanu A-M, Shah AS, Peters F, Ring D. Predictors of pain during and the day after corticosteroid injection for idiopathic trigger finger. J Hand Surg Am. 2012;37(2):237e242. 17. Kamal RN, Kakar S, Ruch D, et al. Quality measurement: a primer for hand surgeons. J Hand Surg. 2016;41(5):645e651. 18. Value-based payment modifier. Centers for Medicare & Medicaid Services. https://www.cms.gov/medicare/medicare-fee-for-servicepayment/physicianfeedbackprogram/valuebasedpaymentmodifier. html. Accessed May 3, 2016.
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22. Clair AJ, Evangelista PJ, Lajam CM, Slover JD, Bosco JA, Iorio R. Cost analysis of total joint arthroplasty readmissions in a bundled payment care improvement initiative [e-pub ahead of print February 24, 2016]. J Arthroplasty. http://dx.doi.org/10.1016/j.arth.2016.02.029. 23. Comprehensive care for joint replacement model. Center for Medicare & Medicaid Innovation. https://innovation.cms.gov/initiatives/ cjr. Accessed May 3, 2016. 24. Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures: a multicenter, randomized clinical trial. J Bone Joint Surg Am. 2007;89(1):1e10.
19. Electronic Health Records (EHR) Incentive Programs. Centers for Medicare & Medicaid Services. https://www.cms.gov/Regulations-andGuidance/Legislation/EHRIncentivePrograms/index.html. Accessed May 3, 2016. 20. Medicare C for, Baltimore MS 7500 SB, Usa M. PQRS Overview. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/index.html. Accessed July 17, 2015. 21. MACRA: MIPS & APMs. Centers for Medicare & Medicaid Services. https://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/Value-Based-Programs/MACRA-MIPSand-APMs/MACRA-MIPS-and-APMs.html. Accessed May 3, 2016.
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