As I was reading a recent news release on the Spine and Joint Solution created by UnitedHealthcare, I searched to better understand the program to determine the success of the program.
Saving employers $18 million is definitely something of which to be proud. I have no idea if the savings has been since the origination of the program or for 2017. My brain immediately began pondering “value-based care.” The definition I associate with the term includes quality and cost. At the same time, in my mind, the patient is at front and center because the program should make a positive impact on the patient’s life.
Through some of the details in the news release, I glimpsed a little bit of how the Spine and Joint Solution provided some level of quality of care. The program reduced readmission rates by 22% and complication rate by 17% for joint replacement surgeries. For spinal surgeries the readmission rates were reduced by 10% and the complication rate reduced by 3.4%. I tend to think that for patients undergoing joint replacement surgery that these outcome changes seemed meaningful. For the spinal surgeries, the changes seem minimal. In reporting readmit and complication rates, I think I would more appreciate knowing number of total surgeries and number of readmits and number of complications. When it comes to readmits and complications, what is the baseline normal expected rate? I mean, zero is unrealistic. What is the expected norm for these rates?
What I didn’t see shared were actual outcomes of how the patient was functioning after the surgical procedure. I mean, we all know that “failed back” surgeries are a thing. We also know that there are patients who are not able to walk up and down stairs normally after a hip or knee joint replacement. Readmission rate and complication rate are the initial quality measures. At some point, the value based care programs need to consider the quality provided outside of the initial 90 days of care. What are outcomes at 6 months and 12 months after the procedures? Granted, in doing so, the payer would have the burden of assessing the real outcomes.
Within the news release, this particular detail affected my thoughts.
Eligible employees saved more than $3,000 in out-of-pocket costs per procedure when accessing a participating facility rather than another in-network medical facility, with incentives such as cash, gift cards, additional vacation days for recovery, and health savings account (HSA) contributions.
The Spine and Joint Solution is a bundled payment program. The employer and payer risk is substantially reduced when the cost is a fixed cost. A known procedural cost that has obviously been set to reap savings for the employer and the payer allowed additional monies to be allocated to employees for incentive purposes. We really don’t know the associated cost for the employers because incentives were also being provided. UnitedHealthcare would have no control or ability to account for this aspect of how the program was implemented by an employer. The reported savings are elevated due to the inability to take into consideration the employer financial incentives.
Although there isn’t an easy solution for alternative payment models, I’d like to think there are three key components that could be negotiated in new contracts when rehabilitation services are included in the care provided to patients.
- Payment not only based on the short term procedure focused on the first 90 days, but also payment inclusive of downstream savings.
- Payment based on long term outcomes that are meaningful to patients.
- Payer has “skin in the game” and includes benefit policies that reward the desired behaviors with substantially reduced deductibles, coinsurance or copays when the care pathway a patient chooses favors the high quality option.
As a bonus, I also think that the payer should also be providing reports to providers. In order for health care to be better, the payers also need to be held accountable with regard to their role, which should be expanded to include more than just monitoring providers, paying bills and focusing on reducing their payments. The payers should be able to provide providers with risk adjusted data about the patients the providers treat, along with how touchpoints with providers affect change in the patient: medication use, health factors, preventative care, and hospitalizations. Payers have more data then imaginable and the time has come that payers need to remove themselves from their silo and begin to create dashboards of information to provide big picture information to providers.
Until next time,