The Revolution of HOPCo – Standardization, Better Care, Lower Cost

Quality over quantity. Primary care and prevention. And the dreaded “S” word—“Standardization.”

What’s the orthopedic world coming to?

It’s coming to a revolution. Are you ready?

OTW checked in on one hospital system that, along with the Cleveland Clinic, is embracing standardization, value-based healthcare (VBHC) and a culture where less is more.

And we think we have seen the future of orthopedic healthcare delivery.

Value-Based Healthcare – VBHC

The Affordable Healthcare Act (ACA), when it was signed into law in 2010, caught the orthopedic care system in mid-transition. Private payers and Centers for Medicare and Medicaid Services (CMS) had been pushing for more risk sharing and outcome-based reimbursement for years.

And, while the ACA triggered lots of debates, one thing became clear—a single-payer system might be able to increase insurance coverage, but it didn’t necessarily solve the problem of rising health care costs.

Enter VBHC.

The traditional fee-for-service model bases payments and financial incentives on the volume of services delivered, irrespective of health outcomes.

It’s an unsustainable model.

VBHC, by contrast, is a more patient-centered payment model which ties incentives to value or quality, as opposed to quantity.

According to a report published in 2016 by The Economist Intelligence Unit, “Value-based Healthcare: A Global Assessment”, value is looking at the full cycle of care cost, comparing it with patient outcomes, plus a greater focus on primary care and prevention. The first thorough presentation of what a VBHC system would look like was outlined by Michael Porter and Elizabeth Teisberg in their 2006 book Redefining Health Care: Creating Value-based Competition on Results.

The Cleveland Clinic adopted the VBHC methods. The Centers for Medicare and Medicaid Services is currently funding seven types of innovation models promoting value-based care.

HOPCo Takes the VBHC Challenge

We’ve been hearing about Healthcare Outcomes Performance Company (HOPCo) and the Center for Orthopedic Research and Education (CORE) in Phoenix, Arizona for years.

CORE is a medical group that specializes in orthopedic, neurology, and spine health. HOPco manages the entire flow of musculoskeletal care, from initial evaluations to post-operative care, for hospitals and orthopedic practices, including CORE. We’d meet their surgeons at meetings and we were hearing amazing reports about the HOPCo system.

Turns out, HOPCo and CORE are also, along with the Cleveland Clinic, leaders in the VBHC revolution.

“The key [to VBHC] is providing the right care at the right time,” said Peter Slate, chief business development officer with HOPCo. “You’re at risk for care, but you’re also at risk for the outcome. We have every incentive to make sure our patients stay healthy and don’t need surgery. If they do, we make sure they get the right surgery, in the right facility.”

The first step in shifting from the traditional fee-for-service to VBHC is the ability to track patient outcomes and costs. This requires high-quality IT system and data infrastructure that takes time to establish. Over the last decade, HOPCo has done just that; the result is a unique software platform, VirtueHealth, that allows them to manage the continuum of orthopedic care for each patient.

From pre-op to post-op care, the system collects data on the entire patient journey. Using that data, they’ve developed predictive analytics that helps them see what a new patient’s likely care pathways are, monitor physician compliance with protocols, and measure patient satisfaction. Ultimately, physicians are incentivized to delivering the best care, not the most care.

The Surgeon’s Perspective

“About 90 percent of the time, most patients fall into certain categories and can be treated in a similar fashion,” said Dr. Ali Araghi, director of CORE’s spinal division. “What we’ve done differently is we’ve had clinicians sit around the table and make the decision on what is the best way to treat something. The patient’s best interests are held in mind by physicians that are practicing surgery daily and understand the workflow better than anyone else.”

Adopting implant and equipment standardization is just as critically important. For instance, typically, a scrub tech for multiple surgeons must learn how to handle and sterilize many kinds of equipment, some of which must be taken apart for the sterilization process and put back together. But under standardization, these procedures become smoother and more efficient.

“The scrub techs that operate with us understands the system much better because they are getting more exposure to it on a daily basis,” said Araghi. “Our sterilization department is now sterilizing just one set of equipment [for a particular surgery] that they are very familiar with and they have half the inventory to learn overall. This reduces cost.”

Standardization??!!!

“Standardization also allows us to see when things may or may not be helpful for the patient, seeing right away when the right care may be going astray,” said Slate. “We’ve done significant research to make the best decision that a piece of equipment or an implant is the right thing to standardize to.”

But standardization is not 100% set in stone; a single company can’t provide everything they need and sometimes a patient may need an implant that isn’t standardized. The goal is to hover around 90% utilization. As a result, there is no penalty for a surgeon that averages, say, 85 % utilization.

“If you’re doing 30 surgeries a month and you decide 29 of them need to use instruments from a different company, that is problem,” said Araghi. “But if you use different implants for 7 of those cases, that’s totally fine, that’s what the patient needed.”

The evolution of technology is also considered. If a new instrument comes on the scene and provides better outcomes than what they currently use, Araghi says they will change standardization to that company. And a company not staying current with changing technology would also be a cause to consider switching to a new company.

“It’s a fluid system that can be changed, but we all want to be flowing down the same river. If we change rivers, we do it as a team,” said Araghi.

Interventions? Less Is More

Cutting down on unnecessary interventions is another area where patient care is improved and cost is abated. If a patient comes into the office with two weeks of radiculopathy (pain, numbness or tingling), and asks for an MRI, most physicians might order it. At CORE, if the patient doesn’t present with any neurological deficits, they hold off on an MRI.

“I spend extra time explaining to my patient that most of these things actually resolve on their own with anti-inflammatory medications or physical therapy,” said Araghi. “Our protocols state that this approach is better patient care because we’re not exposing the patient to a possibly unnecessary MRI and the insurance company saves money.”

As with any process, there is always room for improvement. For Araghi, one area he wants to see gains in is the way he and his colleagues choose protocols. Now, decisions are based more on consensus evidence, rather than true evidence from level 1 studies.

“I would love to see more comparative level 1 studies that would clearly say, for example, with spondylolisthesis, a posterior fusion is better than anterior fusion, or vice versa,” said Araghi. “We don’t have that data yet. So that’s something that needs to be refined, but it’s going to take a lot of academic work.”

Avoiding Culture Wars

Another matter that is tough to crack going forward as more parts of the healthcare system adopt VBHC models, is physician culture. It’s often difficult to change a person’s mind, especially when they are an accomplished professional, and convince them that the way they have been doing something for 20 years may not be the best way.

“I have [physician] friends that say when we have to follow too many protocols, they’re going to retire,” said Araghi. “But these are changes that we have to go through to evolve and get better at what we do.”

It’s not hyperbole to say that VBHC is the wave of the future in healthcare delivery. It’s not a matter of if these changes will be implemented, but when and how.

HOPCo/CORE are members of a modest, but growing group of healthcare leaders all over the world that see the writing on the wall and are doing their part effect change.