Wednesday, February 5, 2020
Creating New Care Models
Dr. Michael Suk MD, JD, MPH, FACS is chair of the department of Orthopedics and the clinical driving force behind the Geisinger ProvenCare® Acute Orthopaedic Programs. He also has a law degree, a Master in Public Health, and served as a White House Fellow who trail-blazed nationwide health programs. He is widely sought after for his expertise in innovative healthcare payment and delivery models and will be speaking at the 2020 Orthopedic Value-Based Care conference. In this in-depth interview, Dr. Suk shares his thoughts about the clinical sweet spot, the jungle of ASC regulations, and where bundles are headed next.
As told to Lauren McGill. Edited for clarity and conciseness.
I am an orthopedic surgeon at Geisinger, which is an integrated and innovative healthcare system. I am also the Chief Physician Officer for System Services, so I am the clinical entity responsible for overseeing our 1.5 billion dollar supply chain for pharmacy and shared services. As we developed a clinically-integrated supply chain, it’s been important to have a physician voice to maintain clinical input into what we’re buying and what we’re putting into people across all service lines with an eye towards cost-consciousness and better outcomes. This is particularly relevant in orthopedics as we strive for quality outcomes with lower costs.
My third role at Geisinger is as the Chair of the Musculoskeletal Institute. The institute is a combination of orthopedic surgery, physical medicine and rehabilitation, physical therapy, wound care, podiatry, and other related departments that related to mobility and the overall musculoskeletal system. The scope and breadth of the job is over 13 hospitals in two different states with 3.5 million patients.
This is the only conference that I know of in the United States that is physician-driven and multidisciplinary with cutting-edge ideas from around the country that are easily emulatabe.
What makes Geisginger’s care model unique?
Geisginger is an integrated delivery system with its own health plan, its own hospitals, and its own physicians, all of which are combined together. As a payer and a provider, you’re usually on opposite sides of the fence – one pays and the other provides. When they work in concert, it’s the clinical sweet spot.
In a traditional relationship, the providers like to charge more because they get paid more. But when you when you combine them, then the more money we charge, the less money the insurance company gets paid. And since it’s all one ledger, ‘robbing Peter to pay Paul’ is something we have to watch very carefully. It drives a lot of our value-based initiatives, which is how Dr. Kain and I first crossed paths, because he was wondering how we could provide warranties for these joints, etc.
What are some of the challenges of keeping up with regulations for orthopedic ambulatory surgery centers?
ASCs have to go through a number of regulatory hurdles in order to qualify for worst case scenario patients, rather than allowing the most suitable patients go through with fewer regulations. It tends to slow down the process – maybe for the right reasons, maybe not.
Regulations actually trail behind the orthopedic innovations. As a result, you see regulations that are somewhat historic in terms of requirements for staffing, hours, beds, and acute care needs. Often times, regulations don’t anticipate or embrace orthopedic innovations, although I think that most orthopedic innovations can be safely done fairly quickly.
There are some transfer requirements that hinder some of the ASCs. These have to do with safety regulations and are not necessarily bad. But sometimes what hinders progress is an ASC needs a transfer arrangement protocol with a larger, more acute care facility and those things continue to be rather ill-defined. There is not necessarily great incentive for an independent ASC to work out an agreement with a local hospital entity who they are taking the business from. Assuming all good intentions and ethics, it still is a business decision that plays a nuanced role in those conversations about transfer arrangements.
As far as reimbursement, the federal payment structures still largely maintain an inpatient. Even though there is now a greater degree of flexibility with regard to paying for outpatient total joints, etc. the incentive is still largely to do it in an inpatient setting. I think that is going to change slowly as we get even more evidence saying these surgeries are safe and easy to do as outpatients.
Lastly, we do have some federal regulations that somewhat inhibit physician ownership of ASCs sometimes. Those are rules intended to protect the public from inappropriate use but I don’t think that it’s black-and-white that physician ownership is automatically a bad thing.
Regulations actually trail behind the orthopedic innovations. As a result, you see regulations that are somewhat historic in terms of requirements for staffing, hours, beds, and acute care needs.
How do you create value within the context of contracting?
In my role, I often wear the supply chain hat which talks about the cost of supply and its role in ultimate value creation. But I like that the OVBC conference really focuses on how to tie patient-reported outcomes with creating some kind of risk-sharing between entities. I think it all boils down to: Where is the risk? Who is sharing in the risk? Is there a gain-share in terms of the savings or a risk-share in terms of the outcome?
How will bundle payments’ role in value-based care change in the future?
I think the bundles have proven themselves to be successful, particularly within orthopedics, largely because we saw a lot of low-hanging fruit in the disconnectedness of that episode. The easiest chunk of money to save was in the post-acute management. When you look at a total episode cost, you see that one-third of the cost goes into a post-acute setting. So we found out that actually patients can go home safely and that it is actually a good thing for them and we actually saved a ton of money.
Now that we’ve cracked that nut, we’re looking for money in areas that are much harder, like preventing readmissions or Emergency Room visits. So we’re doing things like calling patients while they’re at home or seeing them in a same-day clinics. But these are successful tactics for a much smaller cohort of the overall picture. For example, if you are talking about a 3 to 4% readmission rate, you’re talking about a much smaller amount to extract dollars from. In the future, we will get to the point of diminishing returns.
I foresee bundles going beyond the primary total joint. Can we go into the complex total joint? Or the revision total joint? The infected total joint? Or do we move in orthopedics to other areas, like shoulders, wrists, fingers? I think there is still a lot of room to do bundles because it has been an interesting experiment, but I think it could go longitudinally or it could go volumetrically.
Tell me about the Geisinger ProvenCare® Acute Orthopaedic Programs.
For about eight or nine years we’ve been doing ProvenCare®, which is essentially what we think of as the first bundle before bundles. ProvenCare® was designed around this idea that if we were able to get all of our processes right then we could essentially guarantee the outcome of certain episodes. Patients who come in with our insurance and see our doctors in our hospitals get a 90-day warranty on their care so anything that happens within 90 days (an infection, a DVT, etc.) is totally covered and there is no out-of-pocket expense for the patient.
ProvenCare® originally started in cardiac single vessel disease where Geisinger said, ‘Boy, if the nurses do X on time, and we make sure the patients do Y on time, and then we use our EMR to ensure that all happens’ we can virtually guarantee that outcome! Fairly quickly, we extended the concept into total hips, total joints, hip fractures and lumbar spines. Then we re-examined the warranties again and asked: Can we include other episodes? Can we include more complex episodes? Or can we extend the life of the warranty? So today, we actually offer a lifetime guarantee for patients who come through our system, meet a certain set of criteria, and get a primary total knee, a primary total hip, or, as of about three months ago, our first complex revision total knee that was warrantied for a lifetime.
I think there is still a lot of room to do bundles because it has been an interesting experiment, but I think it could go longitudinally or it could go volumetrically.
Why are you looking forward to the OVBC conference?
This is the only conference that I know of in the United States that is physician-driven and multidisciplinary with cutting-edge ideas from around the country that are easily emulatable. There are lots of conferences that talk about value, and it’s usually run by some health system or some administrative group that give presentations in what they’re doing and people say, ‘How the heck am I supposed to do that?’ But I think the OVBC conference is very practical.
Dr. Kain is truly a visionary when it comes to this kind of thing. As an anesthesiologist with a high-focus on orthopedic value, he gives people a focused opportunity to learn from what’s happening around the country. And there’s no proprietary nature to it! It’s an open-book format that allows attendees to copy the success of others. So when I go to the conference and speak, I tell attendees exactly how we do warrantied work and even tell them to call me if they need help with making it happen.
Besides his surgical and administrative roles, Dr. Michael Suk also does work with SHIFT and US Play Coalition advocating the power of play and nature in creating a healthier society. He will be attending and speaking at the Orthopedic Value-Based Care 2020 conference. Find tickets here →
Warranty in Orthopedic Procedures
In this new trend, hospital and medical device companies are now offering various kinds of warranties for patients undergoing orthopedic surgeries. Listen to a panel that consists of both clinicians and medical device representatives.
Changing rules and regulations affecting Orthopedic ASC
In this fast-moving landscape, one must understand the most recent CMS and other regulations that will affect your practice. Hear the perspectives of two orthopedic chairs from two of the largest systems in the US.
Payers Perspective on Value-Based Contracting
All too frequently, payers are missing from conferences that are directed mostly at clinicians and administrators. This panel will include a number of representatives from the large US payers as well as experts in bundle payment models. The discussion will focus on practical aspects of the system.