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Authors

Alexandru Visan, MD, MBA
Member, ASRA Practice Management Committee
President and Cofounder
Executive Cortex Consulting
Miami, FL

Jennifer Noerenberg, MD
Member, ASRA Practice Management Committee
Associate Physician
Southern California Permanente Medical Group
San Diego, CA

Introduction

Integration of the concept of value in healthcare requires an in-depth understanding of the impact of policies and interventions on current and future stakeholders in the essential healthcare structure, as well as their perception of the value proposition.

Major stakeholders in the current healthcare process include, but are not limited to, physicians, payers, employers, patients, and the healthcare system administration. A variety of tools are available to quantify value. Examples include quality metrics (eg, the Center for Medicare and Medicaid Services’s [CMS’s] Quality Payment Program, private payer data analytics tools), cost data, and utilization reviews. National and multinational corporations with a focus on healthcare, technology corporations, and service distribution corporations have an increased impact on healthcare services.

There are general principles, standards, and guidelines that apply to healthcare clinical and managerial processes. At the same time, healthcare is practiced at a local level, and should also be evaluated based on local variations. Variables contributing to the specificity of the healthcare environment include healthcare system financial structures, policies, legal requirements, regulations, governance, payers, employers, data management system, and incentives.

The ability to transform the clinical outcomes of a regional anesthesia and acute pain medicine service (RA/APS) into easily recognized, clinically relevant, and accepted outcomes by the major healthcare stakeholders could lead to increased leverage within the perioperative management infrastructure and beyond.

The recent increase in value-based initiatives (eg, pay for performance, alternative payment models) has created a different set of incentives within the healthcare ecosystem. This brings potential challenges and significant opportunities for leveraging an RA/APS within the perioperative management infrastructure.

National trends toward vertical integration, horizontal integration, and uncharacteristic partnership continue. It is imperative to recognize that these trends represent opportunities to create perioperative management structures that follow principals of process control, increase leverage, and foster outcomes at the levels of episode of care, dis-ease, and population management.

Value Proposition

From a practice management perspective, the strategy of an RA/APS should be to leverage clinical outcomes within the complex stakeholder environment to improve patient care, satisfaction, and outcomes.

Healthcare System Administration (HSA)

Anesthesia and RA/APS could have a major impact in two important areas: operating room efficiency and value base purchasing (VBP).

Operating room efficiency – HSA goals

• Increase utilization rate.
• Decrease anesthesia-controlled time (ACT) and other perioperative times (eg, turnover time, surgical controlled time).
• Decrease perioperative staff time/overtime.
• Indirect metrics: Post-anesthesia care unit (PACU) stay, PACU bypass, time to home or discharge after ambulato-ry surgery, length of stay.
• Increase contribution margin.
• Increase number of cases within normal operating hours.
• Decrease overall operational costs.
• Improve patient and physician/staff satisfaction and retention.

Operating room efficiency - RA/APS goals and strategy

• Design RA/APS protocols for selected surgical procedures.
• Consistently implement RA/APS protocols and standards.
• Identify ideal locations for RA performance with the aim of decreasing the ACT.
• Partner with surgical providers and nursing staff to increase operating room throughput.
• Collect data to determine trends in operating room efficiency and time management.
• Partner with perioperative nursing staff to achieve parallel processing.
• Partner with healthcare entities to identify optimal cost accounting methodologies for identification of potential system savings.
• Improve patient and physician/staff satisfaction and retention.
  

VBP – HSA goals

• Prevent readmissions.
• Lower the rates of complications and adverse events.
• Hospital acquired conditions (HAC).
• Hospital acquired infections (HAI).
• Patient safety indicators (PSI).

VBP - RA/APS goals and strategy

• Prevent readmissions because of pain and pain-related complications through a service targeting populations at high risk.
• Identify the most important strengths within the HAC, HAI, or PSI for an RA/APS to partner with the healthcare facility.

Healthcare facilities are evaluated from a quality, safety, resource utilization, and cost perspective. A multitude of governmental and non-governmental agencies drive these performance metrics. The role of some agencies is limited to monitoring, tracking, or certification and accreditation. Other agencies, through penalties, can influence the VBP of a healthcare facility. An RA/APS can impact the VBP of a healthcare facility by identifying areas that could benefit from specialized services.

Payers

Creating efficient and effective healthcare structures that provide optimal outcomes and minimize unnecessary costs should be an essential component of any payer-driven strategy. Evidence-based medicine, employers, and state and federal agencies establish criteria that shape healthcare services covered by payers. They heavily influence the type and amount of healthcare allowed for various specialties through a complex portfolio of strategies and tactics including medical necessity criteria, local coverage determination, comparative effectiveness evidence, and a multitude of cost control tools (eg, narrow-networks, reference pricing, site-neutral payments, utilization review).

There is a general trend to focus on new episodes of care and disease and population management. An RA/APS should create strategic partnerships to meet current perioperative trends. These major challenges can become opportunities to improve the current system through development of enhanced communication and data sharing method-ologies with payers that would provide a 360-degree analysis of the care continuum and facilitate reductions in total costs of care.

Payers - RA/APS goals and strategy

• Partner with perioperative stakeholders within the framework of perioperative management infrastructures (eg, perioperative surgical home [PSH], enhanced recovery after surgery [ERAS], perioperative enhancement team).
• Create episodes of care, disease, and population management-specific metrics to match the current push for value metrics related to population management.
• Create strong local data management systems focused on clinical and financial outcomes to facilitate collection of resources that could be leveraged during complex contract negotiations.

Employers

Employers play an essential role in healthcare. Most of the working population has employer-based health insurance. Employers have a huge impact on the cost per beneficiary because insurers must develop methodologies to meet their needs. They are motivated to lower the cost of healthcare to maintain financial sustainability and a competitive edge. Downstream effects on employees include faster return to work and decreased disability time leading to lowered long-term costs. Employers value metrics at the level of disease and population management. An RA/APS has limited impact as a standalone service from this perspective.

Employers - RA/APS goals and strategy

• Partner with other providers (eg, primary care providers, surgeons, chronic pain specialists).
• Create care pathways that impact the metrics important to employers.

Patients/Customers/Consumers of Healthcare Services

Numerous factors influence the relationship between patients and healthcare services. Some of the most important are pervasiveness of asymmetric information in healthcare, perception of outcomes, and variability of financial burden.
Patients are not aware of the nuances and complexities of running a healthcare service. They expect constant, reliable, high-quality services and products. At the same time, transparency regarding the true costs and listed prices for delivery of care continues to be a major challenge within the healthcare industry.

Patients/Customers – RA/APS goals and strategy

• Explain the service to patients in non-medical terms.
• Understand outcomes from the patient’s perspective to facilitate better performance in patient outcome surveys (an increasing trend in the outcome survey arena).
• Recognize that patients’ decisions are often based on price, not medical necessity (eg, choosing an opioid instead of a peripheral nerve block for postoperative pain management because of price). The recovery profile and con-cerns about the current opioid crisis might not be as important to patients as we might think.
• Ask questions that are valuable to the patient when designing an RA/APS.

Providing this type of education to patients could minimize some of the uncomfortable questions that payers and providers in healthcare systems have faced in recent years regarding patient financial responsibility (eg, balanced billing).

At the same time, healthcare systems must ask themselves some serious questions.

• Are they providing the same level of service throughout the episode of care (eg, admission to discharge)?
• What type and amount of services can be provided to a self-pay patient that balances quality of care with afford-ability?