It is clear that going forward, regardless of political balance of power, payments for medical services will be increasingly based on whether those services contribute to improvements in the individual’s health and/or population health, as rising spending in health care is unsustainable and increasingly vulnerable to competitive market forces.
Value enhancement for a patient’s care1 is achieved when quality is improved at an equivalent or a reduced cost or maintained at a reduced expense. Partly this can come through reliance on basic business principles to address first-order operational inefficiencies and/or redundancy (eg, negotiating lower prices for supplies and/or drugs, lowering handling and storage costs, streamlining processes). In contrast, value enhancement characterized by reducing unnecessary use of resources during an episode of care (eg, redundant imaging or labs, suboptimal use of medications to treat avoidable complications, unnecessary care) or eliminating potentially avoidable episodes is much more challenging, but it leads to significantly greater impact.
In the context of all these factors and forces that represent opportunities and challenges in population heath, recognition of their specific impact in the domain of perioperative medicine is disproportionately underrepresented. In particular, many opportunities for value enhancement may lie within the management of the most complex episodes of care for the sickest patients.2 , 3 In this patient cohort, early adoption of a multidisciplinary, best-practice care design may offer the greatest promise to improve value when viewed through the lens of population health management. Although the focus of many population health reforms is to prevent or slow the progression of disease, if left unchecked, by 2020, it is predicted that approximately 50% of adults in the United States will have 1 chronic disease, with 25% expected to have multiple chronic diseases, while an estimated 19% of the US gross domestic product will be devoted to health care.4 Additionally, an increasing burden on the health care costs is expected from an aging population—the US population >65 years of age is projected to be 55 million by 2020 and 72 million by 2030.5 Surgical care in particular, which currently accounts for half of hospital admission expenses, is expected to increase as the population continues to age.
We recognize that many opportunities exist for improving value by slowing the progression of disease among patients who are not yet in this high-risk state. Indeed, the healthiest segment of our population is the majority of the population. This “healthy segment,” which subsidizes the insurance pool, represents a relatively minimal expense to the ambulatory and perioperative population health ledger. This is true even when accounting for steps in this population that can slow progression of chronic diseases and reduce the risk of serious acute health events. Conversely, this group represents negligible short-term value enhancement potential when compared to “less healthy” segments of the population (ie, patients with chronic stable or chronic unstable disease). We have witnessed the health care retail market (eg, Walgreens, CVS, Walmart, etc) evolve to competitively offer many of the ambulatory needs of this “healthy segment” (ie, flu shots, minute clinic, urgent care).6 We have also seen the progressively expanded scope of same-day or shortened-stay surgery to create an enhanced value for a “unit of care” to the perioperative healthy population.7 , 8 Telemedicine will undoubtedly continue to evolve to enable further expansion of scope and scale to reach this population.9
Next on the continuum from healthy to complex unhealthy is the segment of the population that has chronic stable disease. This segment has increased long-term risk compared to the “healthy segment” of the population but is for the most part asymptomatic in their day-to-day presentation. The chronic stable medical disease patient represents a segment of the population where minimum to moderate savings may be realized from more effective and proactive implementation of perioperative optimization measures.
While taking action with comprehensive management programs in the chronic stable population can slow or shift progression of diseases and reduce risk of associated perioperative adverse events, the most significant and growing opportunity involves the far end of the continuum in the perioperative patient with chronic complex disease.
Presently, more than a third of inpatient surgical procedures in the United States are performed on adults >65 years of age, a population segment that suffers the highest rates of complications, longer hospitalizations, and greatest loss of postsurgery independence. The average cost of a surgical complication is reported to be approximately $12,000 per episode.10 The elderly and complex chronic disease segments of our population are among the 3%–5% of highest-risk patients who present for surgery and consume nearly 50% of annual health care expenditures. With the continued growth of the complex chronic disease and senior populations, effective and safe perioperative care will become a major priority for health professionals, health systems, payers, and patients. Thus a proactive perioperative medicine policy (and strategy) for this cohort in particular is critical to a sustainable population health strategy.
The risks associated with these complex patients might suggest that they are not well suited for the physician and hospital reimbursement transformation in the United States, which continues to shift from a fee-for-service system to capitated or bundled episode risk-based payment models. After all the goal of these reforms in the view of many is to “incentivize” waste reduction in intensive procedures with the highest costs.
However, such episode-based payments can be viewed differently: giving more control back to the experts in perioperative care, to provide the services in the way that patients need, as an alternative to the continued reductions in fee-for-service prices, and the failure of traditional payment systems to recognize many of the valuable approaches to perioperative care that could enhance outcomes for the most complex patients. In this view, payment reform is much more about alignment than incentives: with limited resources and costs that are too high, giving physicians more control over how those resources are deployed for patients can enable more opportunities for innovation, higher value care, and greater physician satisfaction.
Since risk bearing–shared savings alternative payment models are predicated on reducing spending and/or enhancing quality, these models can permit greater contributions to the value proposition. Current trackable metrics for sources of savings are derived from reducing hospital days, readmissions, emergency department visits, lengths of stay in postacute facilities (ie, skilled nursing), referrals to specialists, and diagnostic testing. Enhancing quality beyond that will come from tracking outcomes and patient satisfaction in a manner different from what is commonly done at the present time—and having the ability to take the actions needed to improve care in ways that truly matter for patients.
The declaration of surgery11 for many patients will likely trigger an important “teachable moment,” in which they can seriously alter lifestyle choices that will reduce their risk for an adverse event during surgery but moreover have sustainable positive effects on reversing or slowing disease progression. The opportunity to initiate and sustain care that heretofore was challenging due to lack of patient motivation will be best served when care coordination between perioperative specialists and primary providers and clinics recognize the value of a sustainable health strategy and appropriately account for the transition of care planning.
These alternative payment models have important limitations, making them challenging as a basis for value improvement. They are based on metrics of value that are imperfect and do not account for factors that influence costs and outcomes beyond physicians’ control, and so performance may vary for reasons unrelated to quality of care. They often provide limited up-front support for needed changes in practice. These are good reasons to implement payment and care reforms incrementally and excellent reasons for perioperative care specialists to engage in shaping the further development of these models (eg, so they better reflect what matters to patients and ensure that promising approaches are adopted). Physician leadership is needed to find ways to improve the value of care and reform payment to support that care.
Going forward, clinicians and health care organizations will need to get more value in care, particularly perioperative care at the most intense end of the spectrum. The sustainability of higher value perioperative care models will be increasingly dependent on their ability to measurably improve quality and avoid costs under bundled, patient-level payment systems. In the present FFS payment system, opportunities exist to directly stand up higher value preoperative programs (eg, anemia clinic, diabetes clinic, nutrition clinic, smoking cessation clinic, obstructive sleep apnea clinic, etc) that improve quality; prevent, reverse, or reduce adverse episodes and therefore cost; and directly contribute to the margin.12 These promising models can be a foundation for further efforts under payment reform.
Having a progressive perioperative care design strategy could provide significant and disproportionately greater return for a unit of care delivery within the continuum of population health. The perioperative care episode begins from the moment of contemplation of surgery to full recovery. Evidence suggests that redesigning the episode of perioperative care to ensure surgery readiness before surgery13–22 and providing standardization of care during23–25 and after surgery26–28 will decrease downstream adverse outcomes, enhance acute care throughput, enable less costly postacute disposition, and reduce overall cost for a perioperative care episode.
Advocating for focused and progressive perioperative medicine policy will depend on demonstrating change that would not have undesirable consequences that outweigh the desired effects of an overarching population health strategy. Perioperative payment reform will need to consider safe, effective, personalized, prevention-oriented care and efficiency. While each health care organization will reflect its own unique blend of roles among administration, physician, nurse, and physician extender specialties, new standards for risk evaluation, perioperative care optimization, and resource utilization using evidence to improve patient outcomes and enhance the value of care will have to be demonstrated or they will be at risk.
Name: Solomon Aronson, MD, MBA, FASA, FACC, FCCP, FAHA, FASE.
Contribution: This author helped in literature research.
Conflicts of Interest: S. Aronson is on the executive business and science advisory board at GeNO LLC, a chief medical advisor for Summus Global LLC, and a consultant for Chiesi USA Inc and Pfizer Inc.
Name: Dev Sangvai, MD, MBA.
Contribution: This author helped edit the manuscript.
Conflicts of Interest: None.
Name: Mark B. McClellan, MD, PhD.
Contribution: This author helped edit the manuscript.
Conflicts of Interest: None.
This manuscript was handled by: Jean-Francois Pittet, MD.
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