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Surgical Perspectives

Optimizing Appropriate Use of Procedures in an Era of Payment Reform

Milford, Creagh E. DO, MPH*; Hutter, Matthew M. MD, MPH; Lillemoe, Keith D. MD; Ferris, Timothy G. MD, MPH*

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doi: 10.1097/SLA.0000000000000738
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In Brief

Accepting financial risk through contracts such as Medicare's Shared Savings Program provides an incentive for health care organizations to adopt effective evidence-based tactics for constraining medical cost growth.1 Reducing overuse of procedures is a commonly cited opportunity to reduce costs with estimated annual savings of $192 billion.2 Reducing the number of inappropriate procedures would simultaneously improve quality while reducing costs. What options are available to providers to monitor and address procedure appropriateness?

The science of appropriateness has evolved since the RAND/UCLA Appropriateness Method was introduced. The term “appropriateness” generally refers to the relative weight of the benefits and harms of an intervention where “the expected health benefit exceeds the expected negative consequences by a significantly wide margin.”3 Importantly, considerable uncertainty still exists for objectively measuring benefits and harms of most interventions, challenging efforts to introduce appropriateness criteria into the daily practice of medicine.

The payer's approach to managing this issue has been to use the burdensome process of prior authorization. Prior authorization criteria frequently lack the specificity of actual clinical situations and the process for exceptions typically involves escalating appeals through clinicians with no responsibility for the care of the patient and minimal ability to weigh the relative benefits and harms of an intervention.

We have developed an alternative approach to assessing appropriateness and managing overuse of procedures. Our approach knits together 4 promising innovations in periprocedural process while remaining attentive to minimizing the unavoidable additional administrative burden. We include in our procedural bundle (1) prospective appropriateness assessment, (2) shared decision making, (3) informed consent that includes personal risk assessment, and (4) collection of procedure-specific outcomes. Although the administrative burden of these additional processes are significant, we argue that these elements of procedural process have the greatest potential to reduce avoidable costs while providing a more effective and more flexible mechanism than traditional prior authorization for meeting patient, physician, and payer goals for efficient high-quality care.

Today, an archetypal patient journey through an episode of care involving a procedure starts with new symptoms (Fig. 1, beneath the arrow). The symptomatic patient seeks care and may consider a procedure. If the physician and the patient agree to proceed, the procedure is scheduled. Procedural outcomes are recorded in the operative note and collected using administrative data, but long-term outcomes are generally not available unless the surgeon participates in a registry specifically designed to monitor outcomes. Systematic adoption of our proposed list of additional processes (Fig. 1, above the arrow) may improve care while reducing inappropriate procedures, but adoption of each of these processes faces specific challenges.

Current state of periprocedural planning shown beneath the arrow. Future state of periprocedural planning includes all elements above and below the arrow. PROs refers to Patient Reported Outcomes. Short- and Long-term outcomes refer to both clinical and patient reported outcomes.


Commonly performed in research studies, documented assessment of appropriateness before conducting a procedure is the gold standard for ensuring appropriateness. Nonetheless, incorporating documentation of appropriateness into routine practice requires substantial investment in document abstraction and data management. In addition, existing guidelines and appropriateness use criteria (AUC) leave considerable flexibility in areas where the evidence base is weak. Consensus on how best to fill the gaps is difficult because physicians are not incentivized to standardize their decision making. Moreover, specialty societies sometimes produce conflicting guidelines for management of the same disease process. For example, the AUC for coronary revascularization identify only appropriateness for coronary revascularization but do not help patients or physicians choose among alternatives.


Patient's preferences for care should be incorporated into the decision making for elective procedures. Although ensuring that a patient fully understands the risks and benefits of a procedure is challenging, patient review of well-designed decision aids enhances the patients' understanding and the quality of his or her decision making.4 Nonetheless, routine integration of tested decision aids into the preprocedural process has proved remarkably challenging.


Providing patients with a clear understanding of the risks of a procedure is a basic tenant of informed consent. Nonetheless, physicians typically convey risk in general terms, using simplified risk scores or population-based complication rates. Although it is possible to provide patient-specific risk scores based on published or local data, producing such assessments at the point of care requires complex data management. For example, The Society for Thoracic Surgeons offers a free online risk calculator to evaluate specific perioperative risks associated with coronary artery bypass graft and valve procedures.5 Many surgeons and their staff use this risk calculator today, but few provide clear written documentation of risks in an easily understandable format or retain records of the risk assessment for external review. Furthermore, the substantial effort required to complete The Society for Thoracic Surgeons risk calculator does not easily fit into a provider's busy workflow. Computerized risk models that are directly linked to electronic health record data can help physicians and patients more precisely and reliably assess patient's risks in a timely fashion during a consultation. Including specific risks on a consent form creates a unique opportunity for the patient and the surgeon to converse more specifically about benefits and risks for a particular procedure. Customized informed consent that includes these personalized perioperative risks can increase the perception of shared decision making and improve risk recall.6


Providers who accept greater accountability for patients will continue to distinguish themselves through routine reporting of clinical outcomes.7 Large-scale registry-based projects such as the National Surgical Quality Improvement Program have demonstrated the significant costs of collecting outcomes data. Even sophisticated registries such as the National Surgical Quality Improvement Program face the challenge of including long-term patient-reported outcomes that matter most to patients.8 Nonetheless, if these obstacles could be overcome, collection and reporting of outcomes data would help physicians improve their outcomes and provide patients with more information for decision making.


How does the ideal patient journey work in practice? We illustrate the process using bariatric surgery. Bariatric surgeons use a predefined set of pre- and postprocedural processes. First, using guidelines initially developed in a National Institutes of Health consensus conference and recently endorsed by the American Association of Clinical Endocrinologists, The Obesity Society, and the American Society for Metabolic & Bariatric Surgery, all patients are assessed using explicit appropriateness criteria that include patient characteristics such as age, body mass index, and severity of obesity-related comorbidities.9 Patients and surgeons who wish to proceed outside agreed-upon criteria are obliged to offer an explanation to the payer to proceed with the procedure. Prospective data collection and observation of long-term outcomes for these procedures offer an opportunity to continuously update guidelines.

Second, patients participate in a structured shared decision-making process that ensures they are fully informed of the risks and benefits of surgery. For example, Massachusetts General Hospital could routinely deliver an existing shared decision-making booklet and DVD on weight loss surgery in collaboration with the Foundation for Informed Medical Decision Making and Health Dialog before the surgical consultation. Patients receive additional SDM materials on the day of their visit with the surgeon. Provision of SDM materials before surgical consultation offers an opportunity for patients to raise specific questions with their doctor during the appointment.

Third, bariatric surgery preoperative consultation often includes an explanation of patient-specific benefits and risks. The approach offers the patient an opportunity to weigh the specific benefits—reduction in body mass index and resolution of comorbidities—and risks of each type of procedure against the other. For example, Massachusetts General Hospital SDM materials compare specific criteria for gastric bypass, sleeve gastrectomy, and adjustable gastric banding such as amount of weight loss dependent on preoperative body mass index, time frame for weight loss, and resolution of diabetes. This information is often calculated manually and communicated during the initial consultation.

Finally, bariatric surgeons ensure that both preoperative and postoperative data are entered into the American College of Surgeons Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program registry.10

Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program participation and accreditation requires reporting 30-day and long-term follow-up outcomes to a national registry with a structured review of associated outcomes. Reporting long-term outcomes serves both to provide patients with more information and to provide surgeons with the information necessary to improve.


Adoption of these periprocedural processes into routine care is likely to improve care and reduce overuse of procedural services, but the challenges described earlier are substantial. Could a combination of technology and incentives spur adoption? These components of periprocedural process constitute a complex information management task and therefore may be amenable to an information technology solution. Much like computerized provider order entry systems for laboratory testing and imaging, procedure order entry systems could be designed to include decision support for the key elements described earlier. Basic requirements include an electronic health record and registries designed to incorporate the data necessary to determine appropriateness while minimizing the burden of data entry.

Even if a decision support technology was available, how should clinicians manage the numerous clinical situations not included in AUC? Physicians will need to establish consensus on criteria not included in specialty guidelines and hold themselves accountable for their performance. Peer case review for exceptions to agreed-upon indications will require a fair process, allowing physicians to proceed against criteria when they and the patient are convinced that the procedure is in the patient's best interest. Valid explanations for deviation from standards should be used to continuously update appropriateness criteria.

As provider organizations take on financial risk, they have an opportunity to align physician compensation with the goals of the 4 process steps described here. Incentivizing collaboration and adoption of the proposed set of periprocedural elements included in our idealized patient journey will mitigate the increased administrative work these processes require.11 Successful adoption will require aligning the incentives between the surgeon and the hospital, with strong support from both hospital and surgical leadership. Finally, adoption of these processes should include thoughtful internal review of individual physician performance and exempt high-performing physicians from payer prior authorization programs.

Some combination of the 4 process steps described here could be considered in alternative payment methods. For example, the inclusion of these process steps could be used as an indication for payment updates. One could envision incorporating our stepwise approach as a requirement for the Centers for Medicare & Medicaid Services Physician Quality Reporting System Qualified Clinical Data Registry initiative. In addition, inclusion of AUC into physician's wRVU updates has already been proposed.12 Proponents of this approach suggest that specialty-specific criteria should be used to determine appropriateness for specialty-based procedures. Physician participation demonstrates their willingness to document the appropriateness of their work and their commitment to continuous improvement.

The 4 process steps described earlier are not new. Taken together, they appear to have significant potential to improve outcomes and reduce costs. Physicians who adopt them will differentiate themselves from their competition and will be doing all they could possibly do to optimize the appropriate use and continuous improvement of procedural services.


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© 2014 by Lippincott Williams & Wilkins.