AANS Neurosurgeon | Volume 28, Number 4, 2019


Comprehensive Quality and Value Programs: The Impact of Hospital Systems and Mergers on the Future of Neurosurgery

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For decades, neurosurgeons have been exposed to iterations of hospital-based quality programs ranging from peer review to quality assurance. Often considered punitive in nature, blame was assigned to an individual physician with expectations of self-remediation. By the new millennium, quality improvement programs were implemented. Although still physician-focused in scope, these initiatives promoted solutions utilizing best practices and/or guidelines. Health-care reform, spurred by escalating costs of care compounded by concerns for quality patient outcomes, has initiated a cascade of transformative changes in the way health care is delivered today. Increasing economic pressures on stand-alone hospitals to comply with federal and state regulations coupled with cost containment strategies employed by Medicare and third-party payors are forcing many to seek shelter and leverage by joining larger health systems. This article addresses the transition to quality and value of neurosurgical health care delivery from a health care system perspective.

A number of forces have prompted quality initiatives that have expanded beyond siloed hospitals into complex medical systems. The Institute of Medicine report, To Err is Human, was in itself transformative regarding quality, noting that the way to limit medical errors required identifying and correcting processes that are variable, inefficient and flawed, rather than merely badgering individual practioners “to do better.” This resulted in a major overhaul as to how quality is viewed and managed today. Furthermore, the adoption of electronic health records (EHRs), advanced financial data acquisition and hospital mergers driven by economies of scale have all set the stage for value based on cost effectiveness and meaningful outcomes.

Hospital Quality
Every hospital has its own unique physician and administrative culture often serving a stable patient population. In this environment, hospitals engage physicians and members of the healthcare team to develop priorities in patient care, cost savings and quality metrics to gauge and drive performance. Metrics can include length of stay, readmissions, instrument costs, OR time, case volume and patient outcomes. This quality data is used to determine reimbursement, compare performance with other like-sized hospitals and plays a role in patient loyalty and marketing. While challenging to set up, as it requires agreement on metrics and a willingness to make changes based on data, a successful quality partnership can help in identifying opportunities and best practices and lead to changes that better serve patients.

System Quality
As changes in health care continue, stand-alone hospitals are economically challenged to remain independent, and perhaps, it is not surprising to see escalating waves of consolidation. However, this is more than an alliance of independent hospitals, but a merging of hospitals to create unified systems with overarching goals. This blending of cultures requires a shift from hospital-centric thinking to working together for the benefit of the system now serving a broader patient population with more diverse needs.

In developing quality programs at a systems-level, every challenge is magnified and has its own set of obstacles and opportunities. Merging hospitals will likely encounter diverse, non-communicating EHR systems during an acquisition phase, making quality data collection difficult. Equally challenging can be the pre-merger financial departments of individual hospitals adapting to the tracking required for economic insight to make solvent system decisions. This can be a daunting experience as clear communication of necessary financial and quality information, with well-defined metrics, is essential for accurate assessment and determination. Keen oversight with patience and a persistent demand for excellence in collecting this data is needed as flawed information can crush physician trust and lead to poor decisions.

Neurosurgical System Quality
Setting up a system-wide quality program for neurosurgery is simply not an expansion of a large hospital-centric quality committee where quality and cost data within the hospital setting are tracked and evaluated. In contrast and in response to an ever-growing Medicare movement towards a value-based purchase environment, a system-wide quality and value committee should tie the clinical events in the hospital to outcomes that go beyond the hospital stay by tracking data in the outpatient setting. This is where the transition and co-relationship in quality and value occurs. 

Hospital systems who have more experience with Accountable Care Organizations (ACOs) are more likely to be very focused and experienced on analyzing costs of episodic care. Take, for example, a single level lumbar fusion: The costs involved from the time the patient is admitted to a hospital and how it relates to the patient’s experience and outcome one year later is a typical way that value is defined. In other words, can neurosurgeons keep the cost down during the surgical treatment and post-op management of lumbar fusion cases while maintaining excellent outcomes for their patients? This is how value will help determine best practices that can be shared with colleagues and be mutually beneficial throughout a system program.

Develop Quality Committees for Future Success
Neurosurgeon engagement is the key element to ultimate success. Considering autonomy as an important element of satisfaction in a physician’s practice, securing a long term goal of value based on what neurosurgeons identify as quality must be recognized and developed. A system-wide quality committee should be composed of neurosurgery thought leaders, each representing their individual hospitals and neurosurgeons, and include key administrators from sectors of finance, operations and nursing support. In the mix of this, understanding the diversity of various practice models of neurosurgery employment in a large hospital system is key to understanding a neurosurgeon’s perspective and may allow for meaningful and necessary variance in opinion. Collaboration and mutual agreement among neurosurgeons and committee members will be essential in identifying appropriate quality metrics to be studied and monitored over time. Furthermore, with the advent of value-based reimbursement, some of these measures have already been identified by Medicare and third party payors and should be included with all elements of measurements formatted in an easily readable document or chart. Finally, and most importantly, cooperation in determining and collecting measurable outcomes outside the hospital’s domain will be needed as both private and hospital-employed groups may require differing forms of assistance or support in securing this information.

In addition to assuring accurate data collection, there needs to be a methodology to allow for continuous review and improvement. At the same time, neurosurgeons should be able to easily identify unnecessary variation in data review, done in a dashboard or similar graphic. A systems quality committee will need to consistently and periodically review materials that the committee members can then share with the neurosurgeons and hospitals they represent. Changes, such as reducing costs in the operating rooms, pharmacy, radiology usage, reduction of wastage and length of stay, may be chosen as metrics for specified episodes of care. Performance is monitored, so as changes occur, data is sent back to those for frequent feedback and assessment.

Flow chart

Impact on Neurosurgeons and Patients
A successful neurosurgical quality/value program requires a partnership between the hospital, the system and neurosurgeons. The goal is to work together to establish a win-win relationship, and tracking your own data while understanding/working with the system should be a high priority.

Data is empowering: See it as an advantage. As bundled payments for procedures are being considered, knowing one’s own data in comparison with others leads to fairness in negotiations. Also, this data can be useful in negotiating equipment needs, appropriate call stipends or employment contracts, block time, OR scheduling and staffing. There are benefits to patients, too. Sharing data can allow for greater opportunities to standardize treatment protocols across a hospital system generated by a larger collective knowledge base. Each day, patients are being faced with higher and higher deductibles. Because of this, many are starting to search for better value in the care they receive. Collected data would be the best way to determine the value of care that all neurosurgeons provide. 

Hospital systems will likely grow both in numbers and size as stand-alone hospitals may become an archaic model for patient care. With this growth there will be a continued push for cost reductions and delivery of services based on quality and value. This will require a new dimension in collaboration between neurosurgeons at a system level and a strong team-based alliance with hospital systems amid similar goals in providing best patient care.

Although challenging during merger processes, accurate data and reporting requires patience and flexibility. The tracking and sharing of quality metrics and verified financial data in a continuous cycle while providing regular feedback will ensure neurosurgeon engagement for the long term and secure a loyal workforce. The individual neurosurgeon has much to gain from these new relationships as the power of aggregate quality data and transparency in outcomes yield opportunities to negotiate collectively with system partners for reimbursement based on value.

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