Charting a Roadmap for Value-based Surgery in the Post-pandemic Era

Abstract

Ten years ago, policymakers sought to renovate American healthcare by replacing its fee-for-service foundations with a value-based care (VBC) framework, which seeks to maximize healthcare outcomes per unit cost of production. To promote this change, payers launched new care models which shifted accountability for outcomes and costs onto providers (ie, physicians and hospitals). However, although the first decade of VBC generated billions of dollars in savings, most progress has been an artifact of modifications to coding and referral practices rather than meaningful transformations to care delivery.1 Surgical care embodies the flaws in the current VBC movement. The field's natural inclination for outcomes measurement and access to technological cost levers make it well-suited for VBC. Yet, surgeons continue to be underrepresented in the design and deployment of VBC models such as accountable care organizations, which in turn have been unable to move the needle on surgical costs.2,3 Even for VBC initiatives targeting surgery – such as bundled payments – the changes in clinical practice have largely been downstream from surgical care (eg, post-acute referrals).4 Given that surgical care accounts for roughly 30% of total healthcare expenditures and 50% of inpatient spending, there is a clear need for future VBC reforms that meaningfully engage surgeons, and their collaborators in anesthesiology and nursing, to reduce costs and improve outcomes.3 Adding to the impetus for change is the COVID-19 pandemic, which has exposed fundamental flaws in healthcare's operating model. The resulting regulatory reforms for service modality (eg, telemedicine), site of delivery (eg, hospital at home), and organization of payment (eg, pressure for site neutrality) have long-reaching implications for both improving value within procedures and better integrating surgical care into the larger care continuum. In this article, we chart a roadmap for surgical leadership in the next decade of VBC. We argue that existing innovation in outcomes measurement and resource management coupled with the competitive pressures of COVID-19 create a unique window for value creation within surgical care. FOUNDATIONS FOR VALUE: FROM MEASUREMENT TO MANAGEMENT Data has always been a rate-limiting step in VBC, as it is impossible to value that which is not measured. Unfortunately, existing measurements contribute to waste and burnout, and new metric development is a lengthy and inflexible process. In contrast, surgery's culture of continuous learning fosters rapid cycle development and longitudinal documentation.5 Consider the American College of Surgeons (ACS) National Surgical Quality Improvement Program and Michigan Arthroplasty Registry Collaborative Quality Initiative, which are highly regarded, risk-adjusted, and validated outcomes registries that were built by surgeons for surgeons. Surgeons are now using these registries to drive the uptake of patient-reported outcome measures, which payers have identified as the next frontier for VBC.6 The field's emphasis on measurement is creating in-roads to clinical integration, with ACS's “Phases of Care” model now incorporated into the Merit-based Incentive Payment System.7 Surgeons can also measure inputs into the cost curve that elude existing VBC initiatives: the supply chain. Specialists are the primary users of new (eg, DaVinci robot systems) and existing (eg, implant selection) technologies for which increased cost may not be proportionate to increased patient value.8 Initiatives for responsible resource stewardship, from time-driven activity-based costing to surgeon scorecards, can improve operational efficiency without compromising care quality.9 Examples such as the Transforming Healthcare Resources to Increase Value and Efficiency Initiative led by ACS and Harvard Business School illustrate how surgeons can access unique levers to increase value in care delivery. These 2 pillars – outcomes measurement and resource