Terms of engagement
A value-based specialist model drives down costs and improves quality for orthopedic patients
Physicians participating in Horizon BCBSNJ’s Episodes of Care (EOC) program outperformed non-EOC colleagues for the same procedures in outcomes, quality and cost.
The finding is based on an analysis of 2017 data for patients enrolled in Horizon BCBNJ’s EOCs for hip replacement, knee replacement and knee arthroscopy.
EOC is the model used to engage specialists in the Newark-based company’s value-based strategy.
The idea was to drive improved outcomes and patient experience and ultimately reduce the overall cost of care.
Doctors who choose to participate in the program are rewarded for achieving better quality of care, lower costs and a more positive patient experience.
When EOC specialists achieve those triple goals, Horizon shares cost savings that they receive in addition to their fee-for-service reimbursements.
“The idea was to drive improved outcomes and patient experience and ultimately reduce the overall cost of care,” said Lili Brillstein, director of specialty care value based models for Horizon BCBSNJ.
Brillstein said that there has been interest in the program — not only in New Jersey but also all over the country.
Lower infection, readmission rates
“We designed the model with our physicians and clinical partners” Brillstein explained In orthopedics, for example, we’ve seen tremendous change in terms of what kind and where patients have their post-acute care in that particular episode.”
When compared to patients in traditional practices, Horizon BCBSNJ members who engaged with an EOC orthopedic doctor incurred a 21 percent lower cost for knee replacements; 30 percent lower cost for hip replacements and a 20 percent lower cost for knee orthroscopies.
In addition, those patients also experienced a 9 percent lower 90-day infection rate after a hip replacement and a 43 percent lower 90-day infection rate after undergoing a knee replacement.
Thirty-day readmission rates for hip and knee procedures were also lower.
Dr. Stephen Zabinski, director of the division of orthopedic surgery at Shore Medical Center and the medical director of total joint replacement at Shore Medical Center and Jersey Shore Ambulatory Surgical Center in Somers Point, said that EOC works across the entire spectrum of patient care.
“It creates incentives for you to create a program that creates value and improves the outcome for the patient. You can see that in real time because as part of involvement of the episode of care program, there is patient satisfaction data that you get back,” said Zabinski.
For example, Zabinski said that providers get information about various patient parameters such as how long they stay at facilities or how long they require physician therapy.
“It ultimately enables you to get data back to validate what you’re doing in regard to patient care and therefore improve patient care. Before that, not all practices had the formal means to obtain information in regard to satisfaction for patients or how long they were requiring services for example.”
Zabinski said that physicians are able to see the data in the EOC program and look at where improvements can be made and the patient experience enhanced.
A Health of America Report by the Blue Cross Blue Shield Association released in January, noted that planned knee and hip replacements are becoming more common among Americans, including people under age 55. Since orthopedic procedures have considerable price variation across the U.S., the report encourages individuals to work with physicians to select a site of care that meets their needs for both quality and affordability.
According to the report, planned orthopedic surgeries are increasingly common among Americans ages 35 to 64, costing more than $25 billion in 2017 — an increase of 44 percent over the past eight years. Since 2010, prices increased 6 percent for knee procedures and 5 percent for hip procedures. Over the same period, knee and hip replacement rates have increased 17 and 33 percent, respectively.
The more than $54 billion in spending to treat all orthopedic pain conditions (including pain in the muscles, bones and joints) represents more than 14 percent of overall healthcare spending for commercially insured adult Blue Cross Blue Shield (BCBS) members.
By examining the medical claims of BCBS commercially insured members from 2010 through 2017, the report identifies trends in cost and quality of care for elective or planned orthopedic surgical procedures (specifically total and partial knee replacements and total hip replacements). It found that planned (elective) orthopedic procedures for commercially insured adult BCBS members cost approximately $25 billion in 2017, accounting for approximately 47 percent of total orthopedic care spending, an increase of 44 percent since 2010.
The increase in the number of knee and hip procedures from 2010 to 2017 is the main cost driver, as the number of knee and hip procedures is up across nearly all ages.
With hip and knee replacements, Zabinski said that the quality of care is directly aligned with cost. “If you’re optimizing your patients before surgery, preparing them and educating them, you can make your pain management techniques and surgical techniques better.”
Zabinski said that looking back at 90-days after surgery, patients should be more satisfied and enjoying better outcomes. At the same time, costs are reduced by avoiding complications and streamlining care to focus on the things that really matter and eliminating the things that don’t.
“This gives us a chance to participate in some of that savings and is a great way to engage doctors and enable them to impact their patients’ care and have them also be remunerated for their impact on patient care.”