New Health Care Paradigms–Trouble or Opportunity?

New Health Care Paradigms – Trouble or Opportunity? Ronald G. Pearl, M.D., Ph.D. Dr. Richard K. and Erika N. Richards Professor Chairman, Department of Anesthesiology, Perioperative and Pain Medicine Stanford University School of Medicine The American health care system is in the process of a major transformation. Currently, the United States spends 2.6 trillion dollars, over 17% of its gross domestic product, on health care with a per capita expenditure more than twice the average of other developed countries but without evidence of improved quality or outcomes. Health care now represents approximately one-fourth of the government budget and costs have been rising faster than inflation. Although the passage of the Patient Protection and Affordable Care Act in 2010 is often viewed as the pivotal event driving health care reform, the reality is that many of the ongoing changes in health care are driven by payers who are searching for new paradigms to decrease costs and share financial risk. This syllabus will review the current status of new health care paradigms and then focus on the potential role of the cardiothoracic anesthesiologist. Fee-for-service reimbursement developed in the 1930s to preserve the autonomy of physicians in health care decisions (Kane, 2008) and remains the dominant method of payment. The fee-forservice systems rewards providers (both physicians and hospitals) for quantity of services rather than for quality and has resulted in a fragmented care delivery system with limited coordination of care among providers and with marked variation in resource use. An example of the problem of the fee-for-service methodology is that hospitals increase their profitability when Medicare patients have surgical complications (Eappen, 2013). The initial change away from a pure feefor-service system has been to modify the payment, either on the basis of meeting specific process performance metrics (such as antibiotic prophylaxis, glucose control, and temperature management) or by not paying for certain hospital-acquired conditions such as central line associated blood stream infections or wrong site surgery. These initial modifications have been expanded to a larger value-based purchasing approach where payments may be modified on the basis of patient outcomes or patient satisfaction scores. These approaches have often involved payment withholds which are then distributed to the higher-performing institutions. Unfortunately, such systems which reward specific process measures may produce negative consequences, such as promoting erroneous practices (perioperative beta-blockade), excess inappropriate care, inappropriate resource allocation, and creating incentives to avoid high risk patients (O’Brien, 2013). Many studies have not demonstrated improved outcomes with increased implementation of process measures. The general lack of success of value-based purchasing based on process measures has therefore evolved to payments for an episode of care such as coronary artery bypass surgery. For Medicare payments, hospitals have received such diagnosis-related group (DRG)-based payments since

1983, but the current methodology for episode of care payments invovles two major expansions. First, the episode of care is defined not just as the hospitalization but also includes the 30 days after discharge, creating incentives for improved coordination and communication throughout this period. Second, the hospital and physician payments (Medicare Part A and B) may be bundled together into a single payment, as initially recommended by the MedPAC 2008 commission (Kane, 2008). That commission also recommended the development of the medical home with a monthly capitation payment for providing comprehensive, continuous care of complex patients. Approximately two-thirds of Medicare beneficiaries with 3 or more common conditions see at least 10 physicians per year, and the current fee-for-service system promotes fragmented, uncoordinated care without adherence to best-practice guidelines. In selected demonstration projects, the medical home concept has improved outcomes with decreased costs (Milstein, 2013). Importantly, the medical home concept is financially viable only with appropriate risk-adjustment payments. The fee-for-service reimbursement system emphasizes high-cost management of acute disease, and the bundled payment and medical home approaches focus on value-based payment (decreased cost and improved outcomes) for individual patients. The final stage in the evolution of health care is the development of accountable care organizations (ACOs) which provide payments for the care of entire populations. Although systems such as Kaiser Permanente function effectively as ACOs, the development of ACOs among academic health care systems has only begun and has faced major financial, cultural, and organizational barriers (Tallia, 2012). By definition, ACOs incorporate concepts of bundled payments and the medical home with a strong emphasis on processes of care including adherence to evidence-based guidelines and pathways, coordinated patient-centered care, and cross-subsidization among specialties. The American Society of Anesthesiologists has strongly advocated for the development of the Perioperative Surgical Home (PSH) as a future model for the role of the anesthesiologist (http://www.periopsurghome.info/). The goal of the PSH is to achieve the triple aim of better health, better healthcare, and decreased costs. It is a response to anticipated changes in health care paradigms and emphasizes patient-centric, physician-led collaborative care with shared decision making and continuity of care for the surgical patient. It incorporates the cost-effective use of non-physician providers. The goal is to align incentives, prevent fragmented and variable care, and avoid preventable harm throughout the preoperative, intraoperative, and postoperative period. It emphasizes involvement of the anesthesiologist from the time surgery is first planned and includes early patient assessment and the use of evidence-based clinical protocols for preoperative testing and medical optimization. The intraoperative period uses best practice protocols to decrease variation. The postoperative period focuses on integrated care, optimal pain management, use of protocols and pathways, and coordination of discharge planning and postdischarge management. The ASA is funding a learning collaborative to develop and disseminate models for the PSH.

There are approximately 500,000 cardiac surgeries performed annually in the United States, and the costs and outcomes dramatically vary among centers for the same procedure. The indications for CABG and valve procedures are well-defined. Implantable cardioverter defibrillators (ICDs), cardiac resynchronization therapy, and heart transplant are cost-effective in appropriate populations, and the improving results with LVAD insertion for destination therapy will likely make this a cost-effective procedure in the near future (Kazi, 2013; Miller, 2013). As a result of the increased age of the population, cardiac surgery procedures will continue to increase (Etzioni, 2011). Based on their high prevalence, high cost, and high rate of complications, cardiac surgery procedures are commonly viewed as an area of potential cost savings in health care reform. Cardiac anesthesiologists can play important roles in this process. Cardiac anesthesiologists are most intensively involved in the intraoperative management of the cardiac surgery patient. The operating room is remarkable for its complexity and the need for seamless communication and coordination between the anesthesiologist, the surgeon, the perfusionist, and nursing. The FOCUS (Flawless Operative Cardiovascular Unified Systems) initiative of the Society of Cardiovascular Anesthesiologists (SCA) Foundation is designed to develop guidelines to decrease human error in the operating room and thereby improve outcomes (http://scahqgive.org/flawless-operative-cardiovascular-unified-systems/). In addition to using superb anesthesia skills and intraoperative decision-making, cardiac anesthesiologists can add value to the intraoperative management of the patient through outstanding communication, adherence to guidelines (e.g., central line insertion bundles), standardization of care, choice of monitoring, and choice of an anesthetic technique to optimize the postoperative course. Since intraoperative care significantly alters postoperative complications, anesthesiologists should also be involved in the development of pathways which include intraoperative glucose control and atrial fibrillation prophylaxis. Adoption of blood transfusion guidelines, point-of-care coagulation testing, and antibiotic prophylaxis can improve value by decreasing costs and improving outcomes. As part of the cardiac surgery team, the cardiac anesthesiologist can help prevent adverse events (Martinez, 2013). Cardiac anesthesiologists can also add value by appropriate preoperative assessment and optimization, including collaboration with cardiac surgeons and cardiologists through attendance at catheterization conference and early preoperative assessment. However, the major area in which cardiac anesthesiologists can expand their value is in the postoperative period. In many institutions, cardiac anesthesiologists are responsible for the postoperative management of the cardiac surgery patient in the intensive care unit. As cardiac surgery has moved towards more minimally invasive procedures and patients have become older and more complex, the postoperative management of patients has assumed an increasingly important role. Even without additional fellowship training in critical care, anesthesiologists are able to treat the major issues which occur in the ICU, such as hemodynamic instability, arrhythmias, bleeding, respiratory

failure, delirium, and pain. These problems may continue after discharge from the ICU, and cardiac anesthesiologists can extend their value by collaborating with cardiac surgeons, cardiologists, hospitalists, nurses, and mid-level providers in the management of the cardiac surgery patient throughout their hospital course, including coordination of care. With their skills in echocardiography and resuscitation, cardiac anesthesiologists can also add value to the institution by developing a service for medical and non-cardiac surgery patients with hemodynamic instability. Finally, cardiac anesthesiologists can add value through careeffectiveness research and implementation of protocols. Selected References: Eappen S, Lane BH, Rosenberg B, Lipsitz SA, Sadoff D, Matheson D, Berry WR, Lester M, Gawande AA. Relationship between occurrence of surgical complications and hospital finances. JAMA. 2013; 309:1599-1606. Etzioni DA, Starnes VA. “The epidemiology and economics of cardiothoracic surgery in the elderly.” Cardiothoracic Surgery in the Elderly. New York: Springer, 2011. 5-24. Kane NM. Traditional fee-for-service Medicare payment systems and fragmented patient care: the backdrop for non-operating room procedures and anesthesia services. Anesthesiol Clin. 2009; 27:7-15. Kazi DS, Mark DB. The economics of heart failure. Heart Fail Clin. 2013; 9:93-106. Martinez EA. Quality, patient safety, and the cardiac surgical team. Anesthesiol Clin. 2013; 31:249-268. Miller LW, Guglin M, Rogers J. Cost of ventricular assist devices: can we afford the progress? Circulation. 2013; 127:743-748. Milstein A, Shortell S. Innovations in care delivery to slow growth of US health spending. JAMA. 2012; 308:1439-1440. O'Brien JM Jr, Kumar A, Metersky ML. Does value-based purchasing enhance quality of care and patient outcomes in the ICU? Crit Care Clin. 2013; 29:91-112. Tallia AF, Howard J. An academic health center sees both challenges and enabling forces as it creates an accountable care organization. Health Aff. 2012; 31:2388-2394.