The Pipeline

Get ahead of the curve: Orthopedics in a pay-for-performance world

Samuel Gold, Service Line Strategy Advisor

Attendees at this year’s AAOS National Meeting turned their focus forward to the potential implications of measuring quality in orthopedic care. The major questions asked were:

  • What are measures by which to measure quality?
  • What role will patient selection play?
  • How will these changes affect a physician’s practice patterns?

Finding ways to gauge success

As providing quality in orthopedic care becomes closely tied to financial reimbursement, orthopedic surgeons are searching for a more standardized method to measure quality and better prepare for a value-based environment. Given the wide range of variables that can affect quality measurement, it is no surprise that there is no single gold standard for accomplishing this just yet. Instead, surgeons and planners turn to a series of patient surveys and functionality measurements to determine the quality of their care delivery. 

The first and most widely used of these assessments is the EQ-5D used to assign a single health score to the patient. Not only does this assessment score the physical performance of the patient, but also the patient’s mental health and ability to care for him or herself. The latter two categories are difficult for providers to affect, but can drastically influence a patient’s satisfaction and recovery.

The key takeaway from these discussions is that planners and surgeons should discuss regular use of these types of scoring systems to better assess their ability to provide quality care and determine strategies to improve in this regard.

Does providing quality necessitate risk aversion?

Recognizing that a patient’s personal health—and not just the state of their acute clinical need—is a strong predictor of their rehabilitative success and perceived quality of care, many AAOS attendees questioned if the focus on quality of care in orthopedics will drive surgeons to be more selective in accepting patients. 

Patients in better general health and with a strong home support system will most likely fare better after surgery, which results in stronger quality scores for the surgeon and hospital. In a pay-for-performance environment, this is vital to the financial position of a practice. Will taking on riskier patients hurt an orthopedic practice?

At this point, it is not known exactly how health policies will mitigate this issue; AAOS presenters point to ICD10 coding as an example of what to expect. This upcoming coding system will include special designations to identify at-risk patients and separate these cases from a physician’s overall quality scoring. Ultimately, the AAOS presenters suggested that surgeons and planners should work together on an at-risk patient identification process and establish protocols to careful manage these patients’ needs.

The super-sub-specialized physician

Volumes are considered the most accurate determinant of success for an orthopedic surgeon; an experienced surgeon will produce more successful outcomes with less risk for error. In a pay-for-performance environment, those physicians who have sub-specialized to gain experience in specific procedures are expected to fare better than general orthopedic surgeons. It was suggested that in very large medical centers, surgeons with lower volumes for specific procedures will be pressured to stick to their higher volume specialty in order to elevate the quality score of that facility and their own practice.

This raises a potential problem for the community-oriented general orthopod. How can they compete with surgeons who are able to subspecialize and therefore, maintain very high quality scores? Unfortunately, there was little in the way of answers offered for this question at AAOS. 

Surgeons in this position will have to compete with specialty practices and with reimbursement policies that appear to award a high degree of sub-specialization. Community hospital planners, in particular, should monitor exactly how payers are rewarding quality to support their general orthopedists during this period of transition.

More from AAOS 2014

Miss our earlier conference coverage? Check out these posts now:

Improving orthopedic quality: Make a strong first impression
What strategies can you use to optimize efficiency in the orthopedic OR?
Metal-on-metal care planning: coordination between patients and providers

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