Supply chain executives will be hearing more about the Perioperative Surgical Home
Michael Schweitzer
Anesthesiologists, surgeons, nurses, respiratory therapists, physical rehabilitation specialists and others are starting to look at the perioperative process in a new way. Instead of viewing it as a series of disconnected snapshots, they are choosing to treat it as one continuous movie, beginning weeks before surgery and not concluding until 30, 60 or even 90 days after discharge.
The concept is being embraced by the American Society of Anesthesiologists who, with the help of Premier Inc., gathered 44 healthcare organizations from across the country to refine what they call the Perioperative Surgical Home – a patient-centered, team-based practice model of coordinated care that guides patients through the entire surgical experience, from the decision to undergo surgery to discharge and beyond.
The ASA is so enthusiastic about the program that at press time it was recruiting healthcare organizations to participate in the next round of the PSH Learning Collaborative, in conjunction with Premier. Round Two is expected to run through March 2018.
New payment models
The Perioperative Surgical Home can lead to better patient care, faster recovery times and lower overall costs, according to proponents. Supply chain executives may notice the difference, as surgeons collaborate to develop clinical pathways and agree on physician preference items, such as orthopedic implants.
It is an approach that is right for the times, says Michael Schweitzer, M.D. That’s because of the growing momentum for value-based payment for surgical services, led by the federal government. Schweitzer is an anesthesiologist and medical director of the Perioperative Surgical Home Collaborative for the American Society of Anesthesiologists. He was recently named chief medical officer of bundled payments for Premier.
Last year, Congress passed the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) in order to make it easier for healthcare providers to take part in two of the Centers for Medicare & Medicaid Service’s quality programs:
- The Merit-Based Incentive Payment System (MIPS), which combines parts of the Physician Quality Reporting System (PQRS), the Value Modifier (VM or Value-based Payment Modifier) and the Medicare Electronic Health Record (EHR) incentive program into one program based on quality, resource use, clinical practice improvement and meaningful use of EHR technology.
- Alternative Payment Models (APMs), including accountable care organizations, patient-centered medical homes and bundled payment models. APMs call for lump-sum incentive payments for participating healthcare providers as well as increased transparency of physician-focused payment models.
No place like home
Using the words “surgical” and “home” to describe the new care delivery model isn’t so far-fetched, says Schweitzer. “First, patients would rather be in their homes than in the hospital or nursing home. That’s why the goal is to get patients back to their own homes as soon as possible. Second, we wanted to use the successful elements and attributes of the patient-centered medical home – which has been around much longer – and build on them.”
A key attribute of the patient-centered medical home is team-based care, says Schweitzer. That means a full team of providers – including physicians, physician assistants, nurse practitioners, diabetes educators, care managers and others – coordinate their efforts to treat the patient. The patient-centered medical home also employs a technique called risk stratification; the primary care team identifies those patients at highest risk of complications and seeks to address those risks in a timely manner in order to avoid negative consequences later.
Similarly, in the Perioperative Surgical Home, “We want to identity high-risk patients and focus on them with a full team of providers who can work with those patients to improve their health, get them through the surgical process and back to their desired functional state,” he says. “It involves a lot of teamwork.”
Difference to the patient
Patients will notice the difference.
“Even as recently as a few years ago, and still in too many locations across the country, the whole surgical process has been totally disconnected,” says Schweitzer. “You have silos of care that don’t communicate with each other, and too often, patients slip through the gaps.”
A case in point might be a total joint procedure (on which the Perioperative Surgical Home Collaborative has focused most of its efforts thus far).
Traditionally, the surgeon and patient meet and set a day for surgery, which could be six weeks hence. “What happens then is essentially nothing,” says Schweitzer. “Then, two or three days before surgery, there is a flurry of activity,” such as lab tests, consults, etc. But two or three days doesn’t give providers enough time to identify and optimize conditions such as anemia or poorly controlled blood glucose levels.
In the Perioperative Surgical Home, on the other hand, “you start implementing a process as soon as a shared decision to have surgery is made,” says Schweitzer. The clinical team might enroll an anemic patient in an anemia clinic long before surgery, and the diabetic patient in a diabetes care program. If the surgical patient’s nutritional habits are poor, the team can identify that and work with that person long before surgery to improve his or her state of health. “And then, you work as a team, with a consistent pathway and goal, so the patient doesn’t slip through the cracks,” he says.
“We are redesigning or re-engineering the whole delivery-of-care process. We look at it from the patient’s point of view. How do we prepare him for surgery? How do we optimize his medical condition prior to coming to the hospital? If we can do that, his physical status will be better after surgery, and he will have a clearer understanding of his own responsibilities after discharge.”
In the Perioperative Surgical Home, the perioperative team helps set the patient’s expectations well before surgery, adds Schweitzer. For example, the physical therapist meets with the patient and instructs her on the exercises she will have to do after discharge. The case manager inquires whether the patient’s home has stairs or rugs, or if she is a fall risk. Does she have someone at home to help her navigate those stairs, rugs and the bathroom in the first days after surgery, or will she need someone from the community to call on her daily? “It is best to coordinate all these things weeks before the surgery, rather than have the care manager in the hospital go over these concerns three or four hours before discharge,” he says.
Making it work
The C-suite’s support is essential to making the Perioperative Surgical Home work, says Schweitzer. And that support seems to be forthcoming.
Facility administrators recognize that narrow margins necessitate taking a fresh look at processes, including surgery, he says. True, they may have a difficult time seeing how the health system can benefit by working with a patient weeks before and after the inpatient surgical procedure. “But when they understand there will be savings, fewer complications, fewer ED visits and fewer readmissions, they will get on board.”
The Perioperative Surgical Home also requires a surgeon champion, anesthesiologist champion, perhaps a hospitalist or internal medicine champion, and others, he continues. Working with the C-suite and project manager, these champions lead the redesign process. Other surgeons and anesthesiologists help design care protocols and guidelines, and are held accountable for following them.
Supply chain and contracting executives can help the clinical team keep down the costs of the Perioperative Surgical Home, adds Schweitzer. The implant itself represents roughly 40 percent of the cost of the in-hospital portion of joint replacement surgery. “And the cost goes beyond the implant,” he says, including pharmaceuticals, durable medical equipment, and other supplies.
Bundled payments coming for joint replacement
Hip and knee replacements are the most common inpatient surgery for Medicare beneficiaries and can require lengthy recovery and rehabilitation periods, according to the Centers for Medicare & Medicaid Services. In 2014, there were more than 400,000 procedures, costing more than $7 billion for the hospitalizations alone. Despite the high volume of these surgeries, quality and costs of care for hip and knee replacement still vary greatly among providers.
That’s one reason why CMS is eager to begin a bundled-payment program for hip and knee replacements. And that also explains why the American Society of Anesthesiologists and Premier have focused on joint replacements in their Learning Collaborative.
On April 1, 2016, CMS will launch the Comprehensive Care for Joint Replacement (CJR) model, in order to test bundled payment and quality measurement for an episode of care associated with hip and knee replacement. The purpose is to encourage hospitals, physicians, and post-acute care providers to work together to improve the quality and coordination of care from the initial hospitalization through recovery.
CMS hopes the alternative payment model will contribute to the Medicare goals set by the Obama administration of having 30 percent of all Medicare fee-for-service payments made via alternative payment models by 2016, and 50 percent by 2018.
The CJR model will hold participant hospitals financially accountable for the quality and cost of a CJR episode of care, and will incentivize increased coordination of care among hospitals, physicians, and post-acute care providers. The episode of care begins with an admission to a participant hospital of a beneficiary who is ultimately discharged under MS-DRG 469 (Major joint replacement or reattachment of lower extremity with major complications or comorbidities) or 470 (Major joint replacement or reattachment of lower extremity without major complications or comorbidities), and ends 90 days post-discharge in order to cover the complete period of recovery for beneficiaries.
The episode includes all related items and services paid under Medicare Part A and Part B for all Medicare fee-for-service beneficiaries, with the exception of certain exclusions.