How to deliver value based surgical care
Arlen Meyers, MD, MBA
President and CEO, Society of Physician Entrepreneurs, another lousy golfer, terrible cook, friction fixer
Transcarent’s aim is “empowering people to be in charge of their entire healthcare experience in one place.” Think of it as concierge medicine on steroids. Users download an app that connects them with a doctor via video or chat within 60 seconds 24 hours a day. Easy issues are dealt with online. For more complex problems, Transcarent will map out the doctors and hospitals with high quality and low costs. It will make an appointment for a second opinion. It will fly the patient to the better facility, rather than recommend a subpar local one. All of this with no premiums, no co-pays and no bills for patients.??
Luma Health, a platform that automates provider-patient communication, has raised?$130 million ?in series C funding.
The San Francisco-based comny aims to simplify patient outreach and reduce administrative burdens by automating aspects of the care experience like appointment reminders, scheduling and patient education. Its platform integrates with over 80 electronic health record systems.
Founded in 2015, the company has raised $160 million to date.
Migrating fee for service care to value based care is an ongoing promise and process. Here is why it is so hard to kill fee for service care.
The United States stands at a crossroads as it struggles with how to pay for health care. The fee-for-service system, the dominant payment model in the U.S. and many other countries, is now widely recognized as perhaps the single biggest obstacle to improving health care delivery. Experts have described the pros and cons of whether capitation or value based care should replace fee for service.
Despite spending about $4T on sickcare that get poor outcomes compared to other industrialized nations, As healthcare prices in the United States have risen over the past several years, more and more Americans are struggling to pay for care.
According to The West Health-Gallup Healthcare Affordability Index and Healthcare Value Index, an estimated?112 million American adults , or 44% of the population, are struggling to pay for healthcare. Worse, more than double––93%––feel what they pay for is not worth it.?
Delivering value based surgical care takes using data to measure the 12 Cs: compliance, conversion, communication, care coordination and accurate cost analysis and pricing, continuous value and behavior improvement and continuity of care and information, consistency in operations, cash to generate profitable growth, caring about patient outcomes and experience above profits, converting data to information and a viable business model canvas.
Are you a Most Valuable Doctor (MVD)? i.e. delivering the optimal quality of outcomes/price?
Value based surgical care promises to deliver higher quality at the same cost or , preferably, higher quality at a lower cost. Delivering on that promise means that patient teams, surgical care teams and third party intermediaries all have to execute on the 12Cs:
1) Compliance with quality standards established by reputable and valid third parties
Physicians practicing in the same geographic area (and even health system) often provide vastly different levels of care during identical clinical situations, including some concerning variations . One practice difference the authors found surprising was in arthroscopic knee surgery rates. In these cases, the top 20% of surgeons performed surgery on 2%-3% of their patients, while the bottom 20% chose this invasive option for 26%-31% of patients with the same condition being treated in the same city.
2) Conversion of patients from potential patients to actual patients along the care pathway and continuum without referral leaks or dropped handoffs.
3) Communication between the surgical team, both internally and externally, referral sources and the patient team
4) Care coordination, particularly with patients who have co-morbid conditions, complications or specific needs. Higher levels of patient engagement before and after the episode of care is a critical success factor. Here are some new models of "care traffic control"
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5) Cost accounting, coding, coverage and pricing that is fair, transparent and accurate. An increasingly important decision is who is responsible for paying for which services during a prescribed episode of care. In addition, more precise coding and documentation needs to be compliant with contract requirements.
6) Continuous value and behavioral improvement based on metrics, analytics and feedback to our care partners.
7) Continuity of care and information which means that surgeons and referral clinicians need to be sure there are adequate pre and post handoff arrangements, particularly for those patients who are traveling away from home for care.
8) Consistency in operations that is difficult given the required hand offs from one department to the next
9) Cash to seed and grow a sustainable business model
10) Caring about patient outcomes and experience above profitability when there are significant financial performance pressures that can place the ethics of medicine in conflict with the ethics or business.
12) A repeatable and scalable business model canvas
Two critical component of executing on these KPIs is surgeon network engagement and data driven decision making using analytics. In essence, sick care companies, more and more, are becoming data companies that happen to take care of patients. Building that environment requires four essential ingredients: ?Culture, Trust, Decision-Making,?and?Local Infrastructure. Until the right environment exists, even the most basic request for change will be shot down.
While many of these tasks are increasingly being solved with technology, like telemedicine, and data analytics techniques like artificial intelligence, they can only be completely solved by person to person interaction that is patient centric. Perhaps the best way surgeons can add value is to not operate at all, but rather recommend non-surgical and less costly alternatives using shared decision making. Unfortunately, there is still too much incentive to do procedures.
Consequently, value based care requires care coordination and communication, risk stratification, patient centricity and managing risk. For those used to practicing fee for service, they will need to learn new skills and create new systems to deliver value.
Delivering value based sick care is a data industry that happens to take care of patients. He who does it best makes the rules and will hold the keys to the kingdom. Are you following Amedzon?
Arlen Meyers, MD, MBA is the President and CEO of the Society of Physician Entrepreneurs on Substack
Professor. Executive. Director.
5 年An outstanding article, 12Cs show the complexity and also the opportunity. The tension in the system is part economic and part political, but as one comes to learn the longer one spends time on the planet, economics trump politics. What is most interesting is that the healthcare structure matters not, the same economic and political tensions that exist in the USA exist in Canada and Europe. What differs are the political drivers, not the economics. Europe likely excels with its two-tier or three-tier systems that can better ration care across 2 or 3 channels.
Chair, Credentials Committee at Christus St Vincent
6 年excellent distillation of the challenges faced to transition to value based care system.