There is no question that surgeons continue to face declining reimbursement rates from government and commercial payors, or that the shift toward reimbursement models that reward value and outcomes can also impose financial and infrastructural burdens on hospitals and practices. However, surgeon reimbursement opportunities could lie in their ability to leverage investments in outcomes data technology.
Take for instance the Centers for Medicare & Medicaid Services’ Comprehensive Care for Joint Replacement (CJR) mandate. Hospitals and surgeons that participate in episode of care models like CJR are monetarily incentivized to meet quality and cost metrics.
“Surgeons have not seen a reimbursement increase in ages, and they take yearly cuts,” says Courtney Hurwitz, Orthopedic Service Line Manager, Center for Bone & Joint Health at Santa Rosa Memorial Hospital (SRMH). “[CJR] is their opportunity to create contracts with their hospitals, and they might actually see an increase in reimbursement rates if their outcomes and successes are all in line.”
Getting to that end point isn’t without additional costs to hospitals and practices that already face extreme price pressures. Investments in programs and technology are required to capture data that can be analyzed and used for long-term success. If correctly implemented and utilized, the cost will pay off as savings are realized through improved outcomes and value, but these investments are undoubtedly onerous upfront.
SRMH uses Intralign’s services to track value-based care in their total joint program. Over the past 18 months, SRMH has achieved $1.5 million in savings by identifying and eliminating waste and optimizing scheduling and patient flow to improve OR efficiencies. Examples included incorrectly assigning surgeon schedules, using incorrect surgery designations and scheduling incorrect surgery time.
One of the core components to controlling the episode of care is integrating technology, says Vince Capasso, Senior Director Operational Process Design at Intralign. The technology must extend beyond collection, though. The data generated—items like cost, quality metrics, care management and patient reported outcomes—has to be understood and accessible by surgeons and staff.
“Access is limited when you consider Electronic Medical Records or EMRs,” says Michael Barr, Vice President of Sales and Marketing at Ortech. “EMRs do a poor job of giving clients the ability to query and mine information.”
Ortech created a web-based system to capture patient reported outcomes. Their patient surveys recommend what to ask patients at each specific time point along a treatment plan. To set up a bundled payment report, the system identifies the data points that need to be captured, such as quality of life, mental health, range of motion and return to activity, Barr says.
“Two-thirds of those data points can be accessed through an EMR, such as readmissions and complication rates,” he says. “But the big gap that our clients have to address is that patient-reported outcome piece. We take the data that patients complete and push it into our registry application. Once we grab the other 2/3 of the data from the EMR, we create an automated bundled payment report that our clients use to negotiate better reimbursement from payors, and to market themselves.”
Surgeons can also spot trends by leveraging data generated from patient-reported outcomes surveys, allowing them to improve their performance and thus, their reimbursement. It’s this information that can empower surgeons to advocate for themselves.
“Now, our clients can say, We expect more and here’s why; we’re starting to collect outcomes and what we have seen is an improvement in pain levels, activity levels and range of motion,” Barr says. “What was once a one-sided conversation has now become a negotiation, and it’s based on data.”
Modernizing Medicine created Electronic Medical Assistant (EMA™), a cloud-based EMR system for orthopaedic procedures. The platform allows surgeons to track outcomes and assists with the billing process.
“If I see a patient and do an injection, take an x-ray and perform the surgery, EMA knows how to assign the billing,” Jason Weisstein, M.D., Medical Director of Orthopedics at Modernizing Medicine, says, adding EMA generates an audit trail, so that the bullet points being accounted for in billing are reflected in that audit trail.
The next phase is incorporating revenue cycle management into EMA, to determine how the system can work best with payors to track what claims are getting paid (or not), levels of surgeon reimbursement per procedure, profitability per certain procedure and why certain procedures are more profitable than others, Weisstein says.
“For physicians to get reimbursed appropriately and promptly, they need a very fortuitous revenue cycle management system in place,” he says. “The goal is to have a system that can efficiently let orthopaedists know where they stand on a month to month basis. Week to week is probably overkill, because things just don’t happen that fast. Month to month systems should be able to generate that type of data.”
While the company is working towards that with EMA, they’ve armed their billing and coding teams with a solid understanding of ICD-10 to ensure that physicians receive appropriate reimbursement.
“With the advent of ICD-10, which has complicated things, you need a system that can immediately recognize and document appropriate ICD-10 coding,” Weisstein says. “We put a huge amount of energy towards entering ICD-10 codes that could be seamlessly generated without crosswalks or big sets of data that physicians would have to look into, at the point of the patient visit. The physician is able to leave with the appropriate ICD-10 code so it can be used, for example, to get pre-authorization for a surgery from an insurance company.”
Ultimately, Weisstein thinks that the technology will continue to play a vital role in patient care.
“Nobody necessarily loves having to adapt, but the time is here,” he says. “Healthcare is changing, becoming more rigorous. We now have the ability to capture data in a structured fashion, and not to detract from the doctor/patient visit.”