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Orthopedists need to define outcome measures for value-based health care
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The value of health care is a central theme to the discussion of health care reform, cost control and alternative payment strategies, and pay-for-performance proposals. Most parties involved in health care delivery and payment would agree that providing the highest value possible is a noble goal, and the benefit should be primarily defined by the patient’s perspective. Physicians desire to provide satisfactory outcomes for their patients and are dedicated to provide better outcomes at lower cost.
However, there seems to be little concordance with physicians, payers and patient representatives as to what is the most useful set of data to define the value or the quality of the care we provide. Furthermore, while we as physicians desire information we believe helps improve our care, that information may not adequately reflect the patient’s perspective on outcomes and often does not include the information third-party and government payers use when considering value-based reimbursement. Due to many different influences, physicians are often confronted with an ever-increasing number of questions that need to be answered by the patient, as well as objective data collected by physicians and professionals who support the practice.
Required data
Anthony A. Romeo
The data set required to report outcomes has been subjectively decided by different members of the health care system who make decisions based on their opinion of what is important to define outcomes. Payers look at population health care issues, such as blood pressure and weight. Orthopedists want to know about objective measures, such as joint range of motion and function. Patient representatives are interested in whether the care was perceived as satisfactory. Outcomes may overlap, but often orthopedic surgeons and patients are challenged to understand the relevance of surveys and tests to fulfill the guidelines or requirements imposed by others who are outside of the direct patient-physician relationship.
The government, employers and others who pay for health care desire to maximize the value of the care they subsidize. Specific data points and questions are now required to achieve what is considered value-based reimbursement. As is often the case, financial incentives dictate priorities, and therefore, required sets of data to maximize reimbursement become the core data set collected. However, this data are not generally valuable to orthopedic surgeons and fail to define outcome or performance in terms meaningful to patient care.
Therefore, we desire to collect additional outcomes as performance measures of care. Many questions remain in the process, including the ability to define meaningful data, methods to collect data, and then create reports that accurately reflect performance and provide insight on how to improve performance. We also would prefer to limit the process to a core set of information that can be effectively collected from patients, minimizing the cost and time burden.
Quality measures
Recent analysis shows that each year in the United States, physician practices spend more than 15 hours per physician per week managing the collection and reporting of quality measures at a cost of more than $30,000 per orthopedic surgeon per year and more than $50,000 per primary care physician per year. Sadly, less than one-third of physicians in the study believe current quality measures represent the quality of care.
Historically in orthopedics, outcome measures have been used primarily from a research prospective to provide details and comparisons regarding patient response to some form of treatment intervention. Generally, this involves groups of researchers following selected cohorts of patients over time with paper or electronic data collection. Outcomes, or the end-result of care, are then reported through a variety of methods including publication in peer-reviewed journals. Numerous external entities require quality measures to provide publicly reported information as well as a basis for “pay-for-performance.” This level of data collection and reporting requires the expansion from specifically defined cohorts to all patients who undergo orthopedic care. The execution of such large scale data collection raises multiple issues that must be addressed to support and protect orthopedic physicians participating in the programs.
Anyone who has participated in a clinical research project recognizes that outcome data collection is a time- and labor-intensive process. Patients must be tracked, contacted and often times coerced into completing surveys and follow-up examinations to allow for statistically valid data reporting. In recent years, electronic data collection systems have allowed for email and text reminders and allowed patients to complete surveys at their convenience using tablets, phones or computer. However, the cost is significant. A recent study reported the financial burden of this process was more than $15 billion when they looked at just 1,000 practices, which were equally divided among cardiology, orthopedics, primary care and multispecialty practices only.
The collection and reporting of quality measures places a significant burden, particularly on smaller single-physician or group practices. The groups may not be able to afford the time and capital investment required to employ systems to facilitate widespread outcome data collection and may continue to contribute to the recent trend away from smaller independent private practice, particularly in medically underserved areas. To be sustainable at all levels of health care delivery, future pay-for-performance models must build in additional compensation for the time, technology and staff required to initiate and operate outcome collection programs.
Patient participation
For an outcome reporting collection to be successful, orthopedic surgeons must have patient participation. Unfortunately, as currently constructed there is little “value” in an outcome program for patients. In our own practice, we have spent the last 3 years designing and implementing an electronic-based outcome program that includes quality measures required by the government and third-party payers, as well as the performance measures to determine subjective and objective outcomes to provide insight for improvements in care and our ability to discuss realistic expectations of care with patients. We use the program to enroll surgical patients into a procedure-specific order set specifying what outcome measures are to be collected at designated time points.
We recently reviewed our patient compliance and noted 45% of patients complete surveys 1 year postoperatively. This low level of compliance introduces significant bias due to loss of follow-up. From a scientific basis, studies reporting less than 50% follow-up would be considered statistically invalid and would never be considered for peer-reviewed publication. Yet, this incomplete and bias data set is expected to provide a basis for value-based reimbursement.
For outcome programs to be successful, there must be some form of patient participation incentive. Incentives can include the ability to provide better decision-making information to future patients, other physicians and the ability to participate in a process that fosters improved care and comparisons with patients who have had similar interventions. However, most likely the only truly successful incentive will be of a financial nature.
A critical issue facing physicians is determining what data are valuable to collect. Data that improves reimbursement are prioritized in most systems. However, for improved orthopedic care, outcome collections should include carefully selected disease-specific measures for a patient population.
Significant variability exists in the literature with regard to the choice of patient-reported outcome measures used by authors reporting on shoulder, elbow and knee surgery. This reflects that even so-called “experts” cannot agree on a core set of data, with the final decisions often influenced by ego as much as science. Designers or participants in the process of developing an outcome tool tend to favor its inclusion in the process of performance measures. The lack of standardization makes it difficult to compare outcomes between different surgeons, authors and techniques.
The true cost drivers for many orthopedic procedures include complications, readmissions or reoperations. Most patient-reported outcome measures do not include reporting of this data, and in large metropolitan areas where patients may present to outside hospitals for postoperative urgent care, there is no standard for identifying and reporting events such as ER visits or readmissions to a secondary hospital. There is hope a consortium of American Academy of Orthopaedic Surgeons leadership, subspecialty society leadership and members of CMS will develop a core set of standardized performance measures for given diseases states. Further development of coordinated systems for tracking and reporting complications is essential.
Remaining challenges
Physicians recognize patient outcomes depend on multiple factors, only one of which is physician performance. Additional influences include patient-related factors, such as concomitant pathology, comorbidities and compliance. For value-based reimbursement to be successful, risk stratification and consideration of additional treatment variables must be included in outcome assessment or the future will include the inaccessibility to care for patients with multiple comorbidities or complex orthopedic conditions.
If improperly assessed, physicians will be penalized for management of these patients even if the care and outcomes is state-of-the-art. In addition, patients must bear some responsibility for their health care. Physicians should not bear the financial burden of less successful outcomes due to poor patient compliance, poor nutrition, obesity, smoking, opioid dependency and other patient-based factors scientifically proven to adversely affect outcomes.
Cost, compliance and risk stratification are just three examples of significant remaining challenges that must be addressed before real value-based reimbursement programs can be fairly and effectively implemented. Physicians and physician-related organizations must be actively involved in the development of the structure and implementation of such programs to protect the interests of physicians and patients. We strive to provide the best possible care to patients, while respecting the requirements and social responsibility for cost-containment. However, as we have seen based on implementation of past policies designed to improve quality, programs that do not adequately address real-world implementation challenges are likely to increase cost, negatively affect patient access to care, report misleading data about physician performance and have little effect on true quality in patient outcomes.
- Reference:
- Casalino LP, et al. Health Affairs. 2016;doi: 10.13777/hlthaff.2015.1258.
- For more information:
- Anthony A. Romeo, MD, is the Chief Medical Editor of Orthopedics Today. He can be reached at Orthopedics Today, 6900 Grove Rd., Thorofare, NJ 08086; email: orthopedics@healio.com.
- Nikhil N. Verma, MD, is the director, Division of Sports Medicine, Department of Orthopedic Surgery at Rush University Medical Center. He can be reached at Midwest Orthopaedics at Rush, 1611 W. Harrison St., Suite 300, Chicago, IL 60612; email: nikhil.verma@rushortho.com.
Disclosures: Romeo reports he receives royalties, is on the speaker’s bureau and a consultant for Arthrex; does contracted research for Arthrex and DJO Surgical; receives institutional grants from AANA and MLB; and receives institutional research support from Arthrex, Ossur, Smith & Nephew, ConMed Linvatec, Athletico and Miomed. Verma reports he receives research support from Arthrex, Arthrosurface, DJ Orthopaedics, Ossur, Smith & Nephew, Athletico, ConMed Linvatec, Miomed and Mitek; has stock or stock options in Cymedica, Minivasive and Omeros; is a paid consultant for Minivasive, Orthospace and Smith & Nephew; receives IP royalties from Smith & Nephew; and receives publishing royalties, financial or material support from Arthroscopy and Vindico Medical Education.