With trends in healthcare moving toward value-based models, the structures that support fee-for-service programs may need to be adjusted or replaced entirely.
The field of population health meshes well with these trends, but how does that interact with medical specialties like orthopedics? In searching for an answer to that question, there is now an example to look at: HOPCo's statewide musculoskeletal population health program in Arizona.
HOPCo Chief Growth Officer Jason Scalise, MD, spoke with Becker's about what such a program looks like, how it works for the average patient, and how payers have reacted to it.
Question: What does a statewide musculoskeletal-focused population health program look like?
Dr. Jason Scalise: A statewide program like the one in Arizona includes MSK specialists as participating providers from across the state. The network of physicians provides coverage and patient access to more than 85 percent of the state's population and is made of physicians from different practices and practice settings. The MSK physicians agree upon and adopt evidence-based pathways and protocols for the entire spectrum of MSK care, both non-surgical and surgical.
For instance, these include best practices around managing knee arthritis as well as knee arthroplasty and, as a consequence, are able to address the total spectrum and cost of MSK care, not just the perioperative range that bundles or episodes of care are typically limited to.
The opportunities for improving quality and value are based on the robust claims analysis and benchmarking data that is brought to the population health program. Participating physicians earn quality incentive bonuses that are linked to adherence to the agreed-upon pathways and protocols, which typically are in addition to their fee-for-service payments for services rendered.
Q: How is all that data used, and what does it look like on the ground level for the average patient?
JS: It truly is a massive amount of data and requires a sophisticated platform to ingest, scrub and correlate it all in a meaningful and clinically relevant manner.
For the average patient, however, these programs are relatively agnostic, which is one reason why they can be rapidly adopted across regions. Patients still see and receive care from their orthopedic physician in the typical manner. There can be some patient-reported outcome measures initiated if not already present, but this is now common for patients to encounter such feedback measures these days.
Q: What have you heard from payers on this program?
JS: The feedback from payers has been very positive regarding the programs, given the consistent results. Payers are looking for physician alignment strategies but are often not best equipped to engage with specialists at the clinical level. Primary care gatekeeper models often have insufficient focus or fidelity to truly optimize the quality and value of specialty care. Such models can also be frustrating for the specialists and patients when care is perceived to be inappropriately delayed, loaded with additional administrative burdens and often do not result in sustainable savings or lasting value.
However, given their proven successes and the ability to drive a much greater magnitude of sustainable value for their members, payers have indicated their intent to replicate these MSK-focused population health programs in other states. As a result, HOPCo is engaged in active discussions with large payers in various states across the country.