Post on 11-Aug-2020
transcript
Building Your Spine Ecosystem:
Leveraging a System of CARE Approach to Improve
Outcomes and Drive Sustainable Growth
Kristi Crowe
Principal, Sg2
Alpesh Patel, MD, FACS
Professor, Co-Director,
Northwestern Spine Center
2Confidential and Proprietary © 2017 Sg2
Developing a Comprehensive Spine Strategy
Can Feel Like Boiling the Ocean
The right spine ecosystem will
thrive in both volume and value.
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Sg2 ANALYTICS
0.4
0.6
0.8
1.0
2017 2022 2027420
500
580
660
2017 2022 2027
Inpatient Procedures Continue Shift to Outpatient…
Note: Analysis excludes 0–17 age group. Spine service line only. Sources: Impact of Change®, 2017; HCUP National Inpatient Sample (NIS). Healthcare Cost and Utilization
Project (HCUP) 2014. Agency for Healthcare Research and Quality, Rockville, MD; OptumInsight, 2015; The following 2015 CMS Limited Data Sets (LDS): Carrier,
Denominator, Home Health Agency, Hospice, Outpatient, Skilled Nursing Facility; Claritas Pop-Facts ®, 2017; Sg2 Analysis, 2017.
–16%
+18%
Spine Inpatient Forecast
US Market, 2017–2027
Spine Outpatient Forecast
US Market, 2017–2027
Discharges
Millions 5-Year 10-Year
Volumes
Millions 10-Year5-Year
+9%
–11%
Sg2 IP Forecast Population-Based Forecast Sg2 OP Forecast
+11%
+11%+6%
+6%
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Sg2 ANALYTICS
8% Neurostimulator
Procedures
7%Other
16%Lumbar/
Thoracic
Fusion
17% Cervical
Fusion
1% Motion Preservation
41% Spinal
Decompression
1%Revisions
8%Vertebral
Augmentation
…But Overall Surgical Growth Is Strong
Note: Spine analysis excludes 0–17 age group and includes Inpatient Major Therapeutic Procedures, OP Procedures—Major. Sources: Impact of Change®, 2017; HCUP
National Inpatient Sample (NIS). Healthcare Cost and Utilization Project (HCUP) 2014. Agency for Healthcare Research and Quality, Rockville, MD; OptumInsight, 2015; The
following 2015 CMS Limited Data Sets (LDS): Carrier, Denominator, Home Health Agency, Hospice, Outpatient, Skilled Nursing Facility; Claritas Pop-Facts ®, 2017; Sg2
Analysis, 2017.
Spine Surgical Forecast
IP and OP, US Market, 2017–2027Spine Surgical Volumes
IP and OP, US Market, 2017
Total Volume: 1.4M
0.0
0.5
1.0
1.5
2.0
2017 2020 2022 2027
Sg2 IP Forecast Sg2 OP Forecast
+5% +9%
+28%
64%69% 72% 78%
36% 31% 28% 22%
Volumes
Millions
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We’ve Reached a Tipping Point…
ASC
OWNERSHIP
PAYER
DEMAND
IMPROVED PATIENT
MANAGEMENT
TECHNOLOGY
CONSUMER
EXPERIENCE
CONSUMER PRICE
SENSITIVITY
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…But Adoption Varies Substantially by
Region…and Market
Sources: Sg2 Ambulatory Market Strategist; Health Intelligence Company, LLC; Sg2 Analysis, 2017.
Massachusetts 1% OP
Alabama 1% OP
Florida 5% OP
Indiana16% OP
Ohio 13% OP
Alaska 43% OP
Arizona3% OP
Nevada 10% OP
Montana 18% OP
NEEDS
UPDATE
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Sg2 ANALYTICS
Sg2 Anticipates Leveling of The Spine Landscape
Note: Analysis includes both outpatient and inpatient procedures and excludes 0–17 age group. Rehab—Initial Evaluations = Rehab—Physical Therapy Evaluations; Rehab
Follow-up Visits = Rehab—Physical/Occupational Therapy; Rehab: Chiropractic = Chiropractic/Osteopathic Manipulation; Procedures—Injections = Procedures—Minor
Arthrocentesis and/or Injections; Visits = Emergent + E&M + Urgent + Observation. Sources: Impact of Change®, 2017; HCUP National Inpatient Sample (NIS). Healthcare Cost
and Utilization Project (HCUP) 2014. Agency for Healthcare Research and Quality, Rockville, MD; OptumInsight, 2015; The following 2015 CMS Limited Data Sets (LDS): Carrier,
Denominator, Home Health Agency, Hospice, Outpatient, Skilled Nursing Facility; Claritas Pop-Facts ®, 2017; Sg2 Analysis, 2017.
Spine Outpatient Forecast
US Market, 2017–2027
12%
17%
23%
13%
16%
10%
12%
–0%
30%
–4%
–3%
13%Rehab
Advanced Imaging
Standard Imaging
Post-Acute Services
Minor Procedures
Visits
Sg2 OP Forecast Population-Based Forecast
9%
8%
13%
17%
13%
15%
14%
11%
16%
5%
–3%
13%
–2%
–4%
–2%
10%
11%
37%
Outpatient Procedure Forecast
US Market, 2017–2027
Rehab: Initial Evaluations
Rehab: Follow-up Visits
Rehab: Chiropractic Visits
Advanced Imaging: MRI
Standard Imaging: Xray
Procedures: Injections
Visits E&M
Visits Urgent
Visits Emergent
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Sg2 ANALYTICS
Building Your Spine Ecosystem Works in Both the
Volume and Value World
Note: Analysis includes both Outpatient and Inpatient procedures; excludes 0–17 age group. Rehab: Initial Evaluations = Rehab: Physical Therapy Evaluations; Rehab Follow up
= Rehab: Physical/Occupational Therapy; Injections = Procedures – Minor Arthrocentesis and/or Injections; Casting = Procedures – Minor: Closed Treatment of
Fracture/Casting/Splinting; E&M = evaluation and management. US = Ultrasound Sources: Impact of Change® 2017; HCUP National Inpatient Sample (NIS). Healthcare Cost and
Utilization Project (HCUP) 2014. Agency for Healthcare Research and Quality, Rockville, MD; OptumInsight, 2015; The following 2015 CMS Limited Data Sets (LDS): Carrier,
Denominator, Home Health Agency, Hospice, Outpatient, Skilled Nursing Facility; Claritas Pop-Facts® 2017
Other3%
Inpatient1%
OP Surgery2%
Imaging16%
Minor Procedures6%
Rehab52%
Visits20%
Orthopedic IP & OP Volumes
US Market, 2017
Total Volume: 542M
Inpatient
~$12B Outpatient
~$34B
IP vs OP Weighted Revenue
US Spine Market,
2016 Medicare Payment Rates
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What Does Good Look Like?
CS – I see a full page photo that somehow
represents the concept of this question
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$$10,000
NCV = nerve conduction velocity.
PHYSIATRIST EVALUATION INJECTIONS
REHAB
SURGEON EVALUATION
PCP EVALUATION
NCV TESTING
CHIROPRACTIC CARE MRI
PCP EVALUATIONMRI
PHYSIATRIST EVALUATIONCOST =
The “Whomever” Model is Costly
…And The Patient Still Might Not
Be Better
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But So Is The Direct to Surgeon Model
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We’ve Got It! Let’s Use The Physiatry
Gatekeeper Model
PHYSIATRY
Mandatory physiatrist
consultation prior to
surgery doesn’t always
deliver the triple aim
Sources: http://www.beckershospitalreview.com/payer-issues/bcbs-of-georgia-to-stop-covering-ed-visits-it-deems-unnecessary.html;
https://www.ncbi.nlm.nih.gov/pubmed/26641851
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How Do Back Pain Patients Choose Their Providers?
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A Spine Program can Take Many Forms
ASC = ambulatory surgery center
Sources: Sg2 Interview With Mayfield Clinic; Sg2 Interview With St. Lukes, March 2017.
Mayfield Clinic (Cincinnati)
Co-located neurosurgeons, PM&R and
rehab in central location
Select PM&R physicians are focused on
evaluation and management of non-
operative patients
Easy access to practice-owned ASC
Patients have easy access to variety of
providers in one location.
Improved communication among
complementary providers
Positioned for value-based contracting
and referral steerage
St. Luke’s Health (Kansas City)
Engaged surgeons and ED physicians in
algorithm development
Established boundaries for overlapping
services between specialties
Establish a provider recruitment strategy
to fill perceived gaps in care.
Reduced referral leakage
Improved surgical conversion rate
Enhanced convenience – spine center staff
can schedule on PT calendar
Increased Surgical Growth
Collocation Models Virtual Models
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Where Do I Start?
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TRACK RESULTS
UNDERSTAND
CURRENT STATE
IMPLEMENT
PROCESS
INCREASE
AWARENESS
DEVELOP
STRUCTURE
A Playbook
for Success
DEFINE THE
PATIENT
PATHWAY
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Sg2 ANALYTICS
60%
25%
15%
Where are Spine Patients Going for Care?
Top 10 Specialties as Percent of Total Spine E&M Visits
Rank Specialty 2014 2016 Change
1 Chiropractor 25% 25% 0%
2 Family Practitioner 15% 15% 0%
3 Unknown* 15% 12% –3%
4 Pain Management Specialist 8% 9% 1%
5 Internal Medicine 7% 7% 0%
6 Orthopedic Surgeon 5% 5% 0%
7Physical Medicine/Rehab
Specialist4% 4% 0%
8 Neurosurgeon 4% 4% 0%
9 Orthopedic Spine Surgeon 3% 3% 0%
10Nurse Practitioner—Family
Medicine1% 1% 0%
*Primarily consists of other 9 specialties listed for claims in which providers did not submit their name or provider ID information.
Note: Excludes 0–17 age group. Surgeons include orthopedic and spine subspecialties only; primary care provider (PCP) includes internal medicine,
family medicine and geriatrics. Volume all. Sources: Sg2 Ambulatory Market Strategist, 2017; Health Intelligence Company, LLC; Sg2 Analysis, 2017.
Total Spine E&M by Specialty, 2016
Chiropractor
PCP
Other
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And How Do Provider Relationships Impact That?
Example: Patients who originate with an affiliated PCP and follow this pathway have a
65% chance of ultimately receiving an IP or OP spine surgery at an affiliated facility.
Notes: Data do not reflect “referrals,” but actual patient activity, which can infer referral patterns; Care Pathway: PCP encounter >180 days > Spine Surgeon visit >180 days >
Total Joint Replacement (TJR) IP or OP Procedure Location. PCP = primary care provider. Sources: Sg2 Patient Flow 2016; Health Intelligence Company; Healthcare Data
Solutions; OptumInsight; Sg2 Analysis, 2017.
NEXT STEP QUESTIONS
Which PCPs send patients to unaffiliated spine surgeons?
Which top unaffiliated spine surgeons receive volumes?
When patients don’t come to our system for a spinal surgery,
where do they go?
100% Affiliated PCP
(400 surgeries)
60% Affiliated
Spine Surgeon (240)
40% Nonaffiliated
Spine Surgeon (160)
90% Affiliated Location (216)
10% Nonaffiliated Location (24)
25% Affiliated Location (40)
75% Nonaffiliated Location (120)
PCP Encounter Spinal Consult IP/OP Spinal Surgery Location
OTHER KEY TAKEAWAYS
Affiliated PCPs have 40% leakage to
unaffiliated spine surgeons.
Affiliated spine surgeons have 10%
leakage to unaffiliated locations
Total IP/OP Spinal
Surgery Count
Affiliated:
64% (256)
Nonaffiliated:
36% (144)
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Access Channels and Full System of CARE Program
Definition are Critical to Future Success
EMG = Electromyography
Home and Community
Community and employer
based education
programs on back injury
prevention
Community fitness
programs
Office or Multidisciplinary Spine Center
Diagnostic imaging (eg CT/MR)
Medical management
Trigger point injections
Physical therapy
Psychological evaluation and support
Hospital OP/ASC
Observation unit (eg medical
back)
Neurostimulator implantation
Pain pump implantation
Epidural steroid and facet joint
injections
Surgical procedures
Hospital IP
Surgical procedures
(eg complex surgeries
including fusions,
scoliosis corrections)
ED
Back pain injury
assessment
Post-Acute Care
Skilled Nursing
Home Health
Outpatient physical therapy
Neuropsychology services
Home Care
Outpatient physical
therapy
Imaging/Diagnostic
Center
X-ray
Neurodiagnostic
services (eg EMG)
CT/MRI
Virtual Health Supports Care Coordination Across the System of CARE
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Optimize System of CARE Performance
CARE = Clinical Alignment and Resource Effectiveness; EMG = electromyography.
Home and Community
Community- and employer-
based education programs
on back injury prevention
Community fitness
programs
Office or Multidisciplinary Spine Center
Diagnostic imaging (eg, CT/MR)
Medical management
Trigger point injections
Physical therapy
Psychological evaluation and support
Hospital OP/ASC
Observation unit (eg, medical back)
Neurostimulator implantation
Pain pump implantation
Epidural steroid and facet joint
injections
Surgical procedures (eg, vertebral
augmentation, simple fusions)
Hospital IP
Surgical procedures
(eg, complex surgeries
including fusions,
scoliosis corrections)
ED
Back pain injury
assessment
Post-Acute Care
Skilled nursing
OP physical therapy
Home Care
OP physical therapy
Imaging/Diagnostic
Center
Neurodiagnostic
services (eg, EMG)
CT/MRI
Virtual Visits
Consults
Follow-up visits
Identify where your SoC gaps exist.
Recognize how utilization of one
service impacts use of another.
Establish the infrastructure to
manage your patients upstream to
facilitate appropriate utilization.
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Sample Spine Program Structure
Surgical Operations
Outpatient Spine
Coordination
Business Development and Marketing
Spine Physician
Advisory Panel
Margin Analysis
Primary Care Physician
Advisory Panel
Lead: Spine
unit nurse
manager
Lead: Spine
center operations
director
Lead: VP of
business
development
Lead: Spine
program
medical director
Lead: Director
of supply chain
Lead: Primary
care physician
executive
Spine Steering CommitteeResponsible for overall spine program strategy development and execution
Members: Senior executive champion(s), VP of strategy,
orthopedics/neurosciences service line directors, rehabilitation
director, and each operational team lead
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Entry Into the Care Continuum Requires
Effective Triage and Navigation
Track 1
“Red flags”
indicating
immediate
surgeon
referral
Track 5
Physical
therapy
series
Track 3
Evaluation by
nonsurgeon
MD, PA or NP
Track 2
Pharmaceuticals
or additional
diagnostics
Track 4
Chronic
pain or
addiction
management
SPINE PATIENTS ENTERING CONTINUUM
Track 6
Therapy
early-
intervention
program
NP = nurse practitioner; PA = physician assistant.
85%
Navigation
Triage
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Multidisciplinary Team Drives Rigor in
Program Execution and Clinical Outcomes
VIRGINIA MASON MEDICAL CENTER, SEATTLE, WA
Multidisciplinary Conference
Weekly meeting based on tumor
board model
Mandatory for every lumbar fusion
surgery
Each case is reviewed for
approximately 5 to 7 minutes.
Each participant has an equal vote.
Source: Melville NA. Multidisciplinary review reduces unnecessary lumbar surgeries. Medscape. May 4, 2017; Yanamadala V et al. Spine (Phila Pa 1976).
2017;42:E1016–E1023.
Results
58% of patients recommended for surgery found to have nonsurgical options.
28% of surgical patients had surgical treatment plan revised.
Zero 30- or 90-day complications; 90-day readmissions for those who had surgery.
Collaboration
Physiatrists
Anesthesiologists
Pain Specialists
Surgeons
Physical Therapists
Nursing Staff PATIENT
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Yesterday’s Metrics Don’t Work in a Retail World
Old Metrics Readmission rates for spine
surgery
On-time surgical starts
Length of inpatient stay
Complication or infection rates
Preoperative education
compliance
Percentage of patients
discharged home
Wait time to initial evaluation
New Metrics New patient to surgery ratios in
surgeon’s office
Percentage of compliance with
MRI guidelines
Return-to-work/functional activity
time
Percentage of improvement in
functional activities
Total cost of care for low-back
pain episode
Referral source satisfaction
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Your Strategy Execution Road Map
Create a collective vision
for your spine ecosystem.
Optimize patient
utilization of
services.
Design a path of least
resistance for
consumers.
Maximize your
OP rehab
footprint.
Account for PCP preferences
and awareness of services.Recognize the benefits of
provider co-location.
Be mindful of surgeon
preferences.
PCP = primary care provider.
Sg2, a Vizient company, is the health care industry’s premier
authority on health care trends, insights and market analytics.
Our analytics and expertise help hospitals and health systems
achieve sustainable growth and ensure ongoing market relevance
through the development of an effective System of CARE.
Sg2.com 847.779.5300
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Successful Programs Share Common Critical Elements
Common Elements of Comprehensive Spine Programs
Access Defined entry point
Timely evaluation
Dedicated care coordinator
Multidisciplinary
Offerings
Conservative care
Pain management
Surgical intervention
Communication Multidisciplinary case review
Regular follow-up with referring physicians
Collection, analysis and reporting of outcomes
Triage Standardized intake process/forms
Physician-directed referral algorithms
Unbiased gatekeeper
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Adequate Expert
Providers
Spine specialty-trained physical therapists
Advanced practitioners
Pain anesthesiologists
Physiatry
CAM
IT Infrastructure Understand total cost of care
Price and outcomes transparency
Electronic capture of longitudinal patient outcomes
Surgical and non-surgical
Chronic Pain
Capabilities
Addiction specialists
Psychology providers
Involvement of pharmacists
Common Elements of Comprehensive Spine Programs
Successful Programs Share Common Critical Elements
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Basic Spine Intermediate Spine Comprehensive Spine
Portfolio Management Is Essential for Spine
Planning
• Structure
• Vision
Program Levels
Outreach
• Marketing
• Outcomes
Clinical
Competency
• Providers
• Workforce
• Multidisciplinary steering
committee
• Program vision
• Measurable goals
• Strategic consideration of
outmigration
• Clear ambulatory strategy
• Long-term Vision for
Recruitment of Providers
And Placement of Facilities
across Market
• Surgeons, PM&R, Pain, OP
Therapy
• Retrospective Pathway
Analysis
• Urgent Care, ED strategy
• Defined referral channels
• Prospective pathway
development
• Care Coordination
• At-risk clinical pathways
(spine surgery/ non-
operative bundles)
• Defined PCP strategy
• Branded materials
• Hospital outcomes
collection
• Centralized triage
• Outcomes used to market
program
• Measurable Goals
• Tertiary care referrals
• Employer outreach
• Virtual health supports
patient outreach