Life is a moving, breathing thing. We have to be willing to constantly evolve. Perfection is constant transformation.
—Nia Peeples (1961–present)
The Perioperative Surgical Home (PSH) model seeks to remedy currently highly fragmented and overly expensive perioperative care in the United States.1,2 The PSH is a patient-centered approach to the surgical patient, with a strong emphasis on shared decision making, rigorous process standardization, and evidence-based clinical care pathways, as well as robust coordination and integration of care.3
This new model of care guides patients and their family members through the complexities of the perioperative continuum, especially during transitions of care, from the decision for surgery to the postdischarge phase.3 This physician-led, collaborative team-based model of care is aimed at improving clinical outcomes, enhancing patient satisfaction, and reducing overall cost.2
Components of a PSH model or an entire PSH model have reportedly been implemented by a large number of organizations,4 both independently and under the auspices of the American Society of Anesthesiologists (ASA) PSH Learning Collaborative (Figure 1).a
However, to date, only a few data-based reports have been published on the benefits and costs of the PSH model.5,6 Thus, the study by Qiu et al7 in this issue of Anesthesia & Analgesia is especially timely and noteworthy because it examined the implementation of a PSH model in the Kaiser Permanente System in California.
This article by Qiu et al7 specifically describes successfully implementing a PSH model within an integrated delivery system (IDS). Broadly speaking, an IDS like the Kaiser Permanente System in California is defined as “an entity that oversees a set of organizations that provide a continuum of care to a defined population and are willing to be held clinically and fiscally accountable for the outcomes and health status of the population served.”8 In practical terms, all of the health care providers are usually on the payroll of the same organization (eg, a single multispecialty group practice) or with a few very closely aligned, mutually contracting organizations.9
This may beg the question for many clinicians, “How does this apply to me?” We ask the reader to first suspend for a moment your preconceived notions about an IDS and its differences from your current practice. Focus instead on the accelerating shift of payments away from conventional fee-for-service (FFS) toward value-based care by both the Centers for Medicare & Medicaid Services (CMS; Table) and commercial payers.10
There are already several CMS or commercial payment options that currently support Population Health Management or Population Health Medicine.11–13 Many of these approaches, such as the Patient-Centered Medical Home, Comprehensive Primary Care Initiative, Comprehensive Primary Care Plus (CPC+), Delivery System Reform Incentive Payment, and to a more moderate extent, the Accountable Care Organization (ACO), specifically target primary care practices (Table).
However, the 2015 Medicare Access and CHIP Reauthorization Act (MACRA) is yet another major shift in payment toward value, which has direct perioperative implications (Figure 2).3,10,14 Specifically, MACRA “put in motion [two CMS] policies to transform physician payments from a system that rewards volume to one that recognizes value.”14 The Merit-Based Incentive Payment System (MIPS) permits clinicians to continue to be reimbursed under traditional FFS, but with their payments annually adjusted, upward or downward, based on their performance on the still-evolving yet only broadly defined domains of: (1) clinical quality, (2) advancing care information (replaced meaningful use of health information technology), (3) resource use, and (4) clinical practice improvement activities (Figure 3).15 The Advanced Alternative Payment Model (AAPM) program is intended for clinicians who elect to participate in alternative practice models (eg, NextGen ACO or CPC+) and hence accept significant shared financial risk for the quality and effectiveness of patient care.15 More approaches are in development or likely yet to be created as new pilots and innovations by CMS or commercial payers.10
Qiu et al7 outlined their patient-centered tactics by using a focus group of 20 patients at the beginning of the development of their PSH model. In addition, they validated and modified their patient-centric methodology with videotaped interviews, which compared the patients’ experiences with the previously existing T-Fast pathway versus the PSH model for total knee arthroplasty (TKA) surgery. As expressed by these authors, engaging patients throughout your development and maintenance of a PSH can be adopted and adapted by anyone. Anesthesiologist and surgeon champions provided leadership. Their planning committee involved a wide variety of stakeholders to support the team-based care. Their Triple Aim outcomes were demonstrated by reduced length of stay (generating internal cost savings for the hospital), increased skilled nursing facility (SNF) bypass rate, and excellent patient satisfaction, with no indication of incremental harm to patients, as demonstrated by no significant change in major and minor complications or 30-day readmission rates.
The analysis by Qiu et al7 would have been strengthened if the authors had shown direct evidence of reduction in total costs instead of the indirect outcomes of bypassing SNFs to home and decreasing hospital length of stay. Bozic et al16 reported in 2014 that postacute care represents 70% of the Medicare expenditure (spend) for a 30-day total joint acute care episode and that an SNF represented an average of 45% of that 30-day postacute care spend. When appropriate, bypassing an SNF by discharging a patient directly to home can thus significantly reduce the total cost of care for total joint surgery.
The Kaiser Permanente System in California, a well-established IDS organization, demonstrated success with utilizing the PSH to redesign the delivery of care within a payment model that innately supports this system of care. Outside of an IDS, the primary barrier is aligning the payment models to support the work of care delivery redesign to provide greater value. What are some tactics of care redesign in a Population Health Management strategy for specialists working toward greater value-based care?
- Relentlessly pursue better health outcomes
- Eliminate patient harm to keep healthy people well and reduce the risks of complications for sick people and thus moderate or high-risk populations
- Engage in a MACRA-approved AAPM such as Medicare Shared Savings Programs (MSSP) Track 2 and 3, Pioneer ACO, or Next Generation (NextGen) ACO, and other advanced payment models (Table) that move further away from FFS toward value-based payment models to achieve better care, smarter spending, and healthier people15,17
- Invest in high-quality informatics infrastructure to focus on data transparency to accelerate performance improvement
- Develop specialty physician delivery models that will qualify as an MIPS Alternative Payment Model (APM) or newly defined MACRA AAPM (Table).
- Test new innovations like the PSH and scale up success rapidly
Strategy and tactics learned from the PSH Learning Collaborative 1.0 are being applied successfully by health care organizations that participate in PSH Learning Collaborative 2.0 and are not an IDS. Engaging physicians and other providers in a cultural change involves behavioral economic concepts such as “salience, relative social ranking, and goal gradients.”18 Salience is a social model for classifying stakeholders. Physician champions have 3 characteristics that make them successful: power, urgency, and legitimacy. Relative social ranking can be leveraged by creating transparency and showing physicians information about actual costs and quality outcomes. This leads to candid discussions with physicians about the value of care they are providing. Physicians naturally care about how they compare with others, especially when they are in their own medical neighborhood. Another influence lever is that people will try to improve their performance when others on the team have a stake in seeing individuals’ performance improve. Instead of all-or-none thresholds for payment model incentives, using goal gradients, people try harder when they are close to achieving a goal and tend not to try as hard if they are far from the goal. The payment models outlined in the ASA PSH Learning Collaborative use both separate individual and team quality goal gradients as distribution criteria. These target performance goals are adjusted over time as the PSH program matures.
This article by Qui et al7 provides much-needed validation for specialists such as anesthesiologists or surgeons of their potential, very tangible contribution toward successfully achieving maximal value-based payments in an APM or AAPM using the PSH model. Nevertheless, advocates and skeptics alike of the PSH model need additional examples of such successful practical experience and confirmatory data to be published. Such evidence will further answer whether the PSH is indeed “more than smoke and mirrors.”
Name: Mike Schweitzer, MD, MBA.
Contribution: This author helped write the manuscript.
Name: Thomas R. Vetter, MD, MPH.
Contribution: This author helped write the manuscript.
This manuscript was handled by: Jean-Francois Pittet, MD.
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2. Vetter TR, Boudreaux AM, Jones KA, et al. The perioperative surgical home: how anesthesiology can collaboratively achieve and leverage the triple aim in health care. Anesth Analg. 2014;118:11311136.
3. Boudreaux AM, Vetter TR. A primer on population health management and its perioperative application. Anesth Analg. 2016;123:6370.
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5. Garson L, Schwarzkopf R, Vakharia S, et al. Implementation of a total joint replacement-focused perioperative surgical home: a management case report. Anesth Analg. 2014;118:10811089.
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10. Vetter TR, Jones KA. Perioperative surgical home: perspective II. Anesthesiol Clin. 2015;33:771784.
11. Kassler WJ, Tomoyasu N, Conway PH. Beyond a traditional payer–CMS’s role in improving population health. N Engl J Med. 2015;372:109111.
12. Peterson TA, Bernstein SJ, Spahlinger DA. Population health: a new paradigm for medicine. Am J Med Sci. 2016;351:2632.
13. Sessums LL, McHugh SJ, Rajkumar R. Medicare’s vision for advanced primary care: new directions for care delivery and payment. JAMA. 2016;315:26652666.
14. Doherty RB. Goodbye, sustainable growth rate-hello, merit-based incentive payment system. Ann Intern Med. 2015;163:1389.
15. Clough JD, McClellan M. Implementing MACRA: implications for physicians and for physician leadership. JAMA. 2016;315:23972398.
Copyright © 2016 International Anesthesia Research Society
16. Bozic KJ, Ward L, Vail TP, Maze M. Bundled payments in total joint arthroplasty: targeting opportunities for quality improvement and cost reduction. Clin Orthop Relat Res. 2014;472:18893.