orm_april-2024 - 22

OR BUSINESS
BY DAVID COTRISS
How data puts the 'value' in value-based care
hat if a surgeon decided to
perform a procedure on a
patient that was not totally
necessary? It happens more often that
one might realize. As recently as August
2023, Forbes published an article that
cited a Harvard Business Review report
stating that over 50% of lumbar spine
surgeries are " deemed unnecessary. "
The article notes that US providers face
increasing scrutiny over " supporting
high rates of unnecessary elective surgeries,
putting profits before patients. "
However, the prevalence of unnecessary
procedures is more than just an
ethical issue. The problem is systemic,
driven by a traditional, fee-for-service
(FFS) reimbursement model that prizes
quantity over quality. The more procedures
a surgeon performs, the more
that surgeon gets reimbursed. In addition
to driving up direct healthcare
expenses and administrative costs, the
additional procedures and services incentivized
by this traditional model do
not necessarily focus on preventative
care or result in improved patient outcomes.
As
a result, the federal government
created value-based care (VBC) programs
to reduce medical expenses and
improve patient care. Unlike the FFS
model, in which providers file claims
for services or procedures, VBC reimburses
providers for favorable patient
outcomes. Based on progress so far,
the most successful organizations will
be the ones that are most adept at
deriving insights from data, which is
critical to ensuring efficiency, improving
reimbursement rates, and improving the
quality of care.
Quality over quantity
The transition to VBC is well underway.
In fact, the Centers for Medicare and
Medicaid Services (CMS) anticipates
that 100% of traditional Medicare beneficiaries
and the majority of Medicaid
beneficiaries will be engaged in VBC by
2030.
22
OR Manager | April 2024
W
With an emphasis on integrated
care, the VBC model treats the patient
as a whole-managing their physical,
mental, behavioral, and social needs.
By analyzing data such as medical history,
test results, medications, and
interventions, healthcare teams can
recognize patterns, helping them understand
areas of improvement. For
example, a patient may be living in poor
conditions that may contribute to deteriorating
health and make complications
or readmissions more likely. Better insight
into a patient's overall health situation
enables caregivers to recognize
patterns and adopt a more proactive
approach to intervention.
tor Young Juhn, MD, MPH, who was
the keynote speaker at this year's OR
Business Management Conference in
Phoenix, Arizona, the index provides a
means of incorporating SDOH in care
delivery as well as in research.
SDOH insight could be useful for diverse
teams of clinicians seeking to
collaborate in a VBC arrangement, with
each team member simultaneously
focused on improving individual care
based on patient-specific, health-related
expenses and metrics. For example,
one application of the HOUSES index
linked education and income levels to
the risk of postoperative opioid abuse.
Another revealed the impact of unmet
SDOH on cancer mortality.
beneficial
Providers may
be rewarded if
data show aboveaverage
results.
Traditionally,
insurance companies,
Medicare, and national organizations
define quality of care by measuring easily
quantifiable events like hospital readmissions
and surgical site infections.
However, VBC's more holistic approach
to care requires accounting for other
types of information as well, such as
social determinants of health (SDOH,
which consist of social and environmental
influences such as lack of food or
transportation).
Addressing the significant challenges
health systems face in accounting for
SDOH requires new tools and strategies.
One example is the Mayo Clinic's
Housing-Based Socioeconomic Status
(HOUSES) index, which uses publicly
available property data to measure socioeconomic
status (SES) at an individual
level. As detailed by co-invenAccounting
for SDOH can also be
in meeting traditional definitions
of care quality. For example,
lacking knowledge of patient-specific
barriers to care may lead to higher readmission
rates and, by extension, a
lower reimbursement rate.
However ,
focus -
ing more on SDOH is
not the only example
of how providers are
changing their approach
as the industry transitions
to VBC. In certain
specialties, limiting
care valuations to traditional
metrics can paint
Michael
Reinhorn, MD,
MBA, FACS
an incomplete picture of how quality
varies among providers. For example,
readmissions and surgical site infections
are rare in hernia repair, says
Michael Reinhorn, MD, MBA, FACS, cofounder
of Boston Hernia and Associate
Clinical Professor in Surgery Tufts
University.
To gain insight on other measures
of quality, Reinhorn participates in the
Abdominal Core Health Quality Collective
(ACHQC), a nonprofit that collects
and aggregates health information to
help improve abdominal core and hernia
patient care. " ACHQC identified
validated quality of life tools as the
www.ormanager.com
https://ehrintelligence.com/news/best-practices-for-integrating-sdoh-data-into-the-ehr http://www.ormanager.com

orm_april-2024

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