A UPMC program that helps patients "prehabilitate" in preparation for elective surgery is helping reduce postoperative mortality, complications, readmissions, and longer ICU stays.
A new tool deployed at the VA and the academic medical centers of the University of Pittsburgh Medical Center is helping to evaluate patients prior to surgery and has the potential to dramatically improve outcomes.
The algorithmic tool encourages physicians to speak with surgery patients who the tool flags as being at risk for complications, to ensure the patients will survive and thrive following an elective surgery, says Daniel Hall, MD, an associate professor of surgery at the University of Pittsburgh and a staff surgeon at the VA Pittsburgh Healthcare System.
Hall helped develop the tool after it was first proposed by Jason Johanning, MD. Johanning, chief of surgery at the Omaha VA Medical Center, recognized that mortality post-surgery was higher than it should have been based on variability, suggesting that some patients were dying due to high-risk for postoperative complications because of their "frailty" prior to surgery.
"I got involved in late 2014 and 2015 after [Johanning] had been doing this for two or three years, but he didn’t have resources to validate the tool in any meaningful way," says Hall. "The two of us teamed up and developed a risk analysis in a cohort of between 6,000 and 7,000 patients."
Hall brought the data to clinical leaders at UPMC and says it "caught their imagination."
Even before the final data was published in the Journal of the American Medical Association in 2017, Hall says UPMC implemented the frailty index tool to evaluate all new patients presenting to surgical clinics across the system.
UPMC built the tool into its EMR infrastructure by July 2016 to measure the 14 variables that make up the risk analysis, and incentivized physicians to evaluate their patients using it.
UPMC allocates a portion of physician compensation to each department to encourage quality improvement projects.
That chunk of money is contingent on clinicians meeting benchmarks of desired behavior, Hall says. To qualify for the frailty index portion, physicians were required to conduct the risk assessment on 80% of new patients, a threshold which Hall says physicians met quickly.
But evaluating risky patients is only one part of the equation. Physicians then must intervene to suggest patients improve their health before surgery.
For this reason, UPMC established its Center for Presurgical Care, one of the referral destinations for such patients (they could also be referred back to their primary care physician or to the musculoskeletal clinic for joint problems, for example).
At the CPC, patients can go through a prehabilitation protocol, to better prepare them for the rigors of surgery and hopefully, improve their post-surgical prospects, says Mary Kay Wisniewski, a senior improvement specialist at the Wolff Center of UPMC, the system's quality improvement arm.
Prior to working with Hall, Wisniewski says the Wolff Center had been collecting data on surgery and outcomes.
One interesting group of data showed that one of the system's AMCs had done more than 60,000 elective surgeries, and 13% of those patients were high risk. Post-surgery, those patients accounted for 30% of ICU admissions and a large portion of postop deaths, she says.
Hall's frailty index tool was much better than other tools available that were focused on certain conditions or body systems, Wisniewski says.
"We needed to really understand where we can help patients improve before surgery," she says. "Undergoing two hours of anesthesia is as stressful as running a 5k race. Would you run that race without being prepared?"
That analogy got traction and interest from surgeons, she says.
The CPC focuses on patients the surgeon thinks can benefit from prehabilitation. It employs surgery coaches, generally advanced practice providers, who help patients with nutrition, weight management, exercise, pain management, mental health, smoking cessation, and goals of care, pre-surgery.
"We have algorithms that help surgery coaches follow a pattern and care plan," says Wisniewski.
As a scientist, Hall says while strong evidence clearly shows outcomes, including mortality readmission, length of stay, and complication rates, are all related to the frailty score—the evidence base for intervening is not yet fully developed.
The hope is, however, that as the evidence base increases and as surgeons and other clinicians become familiar, frailty will factor in how patients and doctors will interact over a surgical decision.
Prehab is difficult
While such interventions are proven effective, they are challenging to actually accomplish, Hall says. Controlling diabetes and weight, for example, are important even for patients who are not candidates for surgery, yet are tasks often difficult to accomplish.
"There is a motivating force in telling patients we know they are at higher risk with surgery. Let’s use the event of surgery as occasion to adopt health practices that are not rocket science," he says.
And though the frailty score is associated with markers of cost, readmission, and length of stay, it's still too new to show a bending of the cost curve across an entire system, though there have been smaller pilot studies on that, Hall says.
Right now, the tool is for patients who are vulnerable, says Wisniewski, but there's huge potential in a large system such as UPMC to improve outcomes over a much larger population.
"This is just the beginning. Eventually, we should have all patients coming to the center," she says. "So far, we’ve helped over 400 patients at three hospitals, but outlying community hospitals are also interested, and there's potential in doing this through telemedicine."
Health insurers' vertical integration strategies will pressure hospitals, but the formation of a generic drug company should lower their costs.
Health insurers' strategies of acquiring physician groups and other non-acute care providers will put further pressure on the volumes and margins of hospitals, says bond rating agency Moody's in a quarterly report.
Other mergers that seek to add a large pharmacy chain to a health insurer and one that will combine an insurer with Kindred's home health and hospice business will also pressure hospitals' margins. But hospitals' plan to band together to form a generic drug company would reduce pressure on hospital margins at the same time.
Moody's, which rates bonds issued by hospitals and health systems, couches these developments in the terminology of "credit positive" and "credit negative." Overall, hospitals need to continue to seek to differentiate themselves via their market presence, quality reputation, breadth of services, and cost profiles, the agency says.
CVS/Aetna: Hospitals will have to compete directly with CVS's 1,100 Minute Clinics in certain outpatient services, some of which already provide diagnostic and primary care services such as blood draws and diabetes care. Both CVS and Aetna have committed to expanding those services if the deal closes, but there are still some questions about whether it will.
Humana/Kindred: Instead of directing patients to hospitals that have home health and hospice units, should the acquisition succeed, Humana will redirect patients to the 40% of Kindred's home health and hospice business that it plans to acquire, says Moody's. Humana, which is also in the process of being acquired itself by Walmart, will use the Kindred facilities it purchases to directly affect outcomes for patients with chronic illnesses, meanwhile reducing expensive emergency room visits and hospitalizations.
Optum/DaVita: Optum's planned acquisition of DaVita Inc's medical group, delayed at the moment because of FTC questions, will further pressure hospitals because physicians hold the majority of the influence over where patients will be treated. This has always been the case, of course, but Optum's affiliated health plan, UnitedHealthcare, should be able to carve out more hospitals or certain from its contracts, putting further pressure on margins, Moody's says. By owning more physician groups, Optum should be able to move more quickly to a full-risk, population-based model that would put full control of the premium dollar in the hands of physicians instead of hospitals.
Generic Drug Company: Several large nonprofit health systems, including Intermountain Healthcare, Ascension and SSM Health have announced plans to jointly develop a generic drug company in consultation with the Department of Veterans Affairs. Hospitals have been struggling with the high cost of so-called hospital-based generics, which have weakened their margins. The plan is for the company to gain U.S. Food and Drug Administration approval and it would either make certain drugs or subcontract with contract manufacturers to make them, though which drugs it would manufacture and when they would come to market is uncertain, according to Moody's.
By combining their self-insured plans for a third-party administrator bid, the health systems hope to reduce administrative costs, but that's just the beginning.
Six New Jersey health systems that self-fund their employee health benefits are combining their nearly 50,000 employees and dependents under a single health plan that they hope will be able to cut costs and improve access to high-quality healthcare.
Atlantic Health System, CentraState Healthcare System, Holy Name Medical Center, Hunterdon Healthcare, St. Joseph's Health, and Saint Peter's Healthcare System, all of which will remain independent, formed the Healthcare Transformation Consortium, which will select an insurance carrier as a third-party administrator through a competitive bid process.
The six systems liken their combination to the recent announcement that Amazon, Berkshire Hathaway, and JPMorgan Chase will join forces to attack high healthcare costs and inefficiency.
The consortium says it thinks it will be able to reduce administrative fees associated with providing healthcare benefits.
Moreover, it will eventually serve as a model for other self-insured employees and could be replicated nationally, says Kevin Joyce, vice president of insurance networks for Atlantic Health System, a six-hospital health system based in Morristown, New Jersey, who proposed the deal.
"It certainly hasn't been done in this state before," he says.
It's ironic that health systems that are in part responsible for high healthcare costs are themselves victims, but that truth represents the pernicious and complex reasons healthcare costs so much.
Atlantic Health System, for one, has already implemented several value-based strategies on the healthcare delivery side and has made great strides in value through its ACO, which has more than 390,000 attributed lives.
While the ACO is one way to help reduce costs and improve efficiency, Joyce says this effort is another bold attempt by the health system to leverage its heft as an employer along with other large employers in the state to improve value.
"We're really looking at it from an employer's perspective," says Joyce. "We're self-insured, so we spend a lot of money there, and we're looking to reduce those costs and hit the triple aim for our employees and families."
Combined, the six health systems spend more than $250 million a year for health benefits.
Even though many of them have had limited success in improving value through benefit redesign and better use of analytics to determine appropriateness of certain care protocols, the ability to bring together a quarter billion dollars in annual spending should bring benefits right away, says Kevin Slavin, president and CEO of St. Joseph's Health, a three-hospital health system based in Paterson, New Jersey.
"Each of us have had our different strategies to reduce costs and improve care for our beneficiaries, but now we have six systems that can share those ideas and harness power together," he says. "We believe we'll see immediate in savings cost per enrollee."
The consortium will be expected to further develop ideas for improving utilization and implementing population health strategy. Committees with representatives from all six health systems have been set up and are meeting, Joyce says.
"We're a small state, yet there are variances," he says. "We'll be developing best practices around some of those variances that will help drive the value proposition for us but also for other payers who use us as providers."
Though it's early, part of the strategy may involve forming a narrow network of healthcare organizations making up the consortium, because as a contiguous group of non-overlapping health systems, many employees from all six systems can be found in each other's markets and seek care there already, says Slavin.
"Our employees live in each other's marketplaces," he says. "There's potentially a network there in the central and northern part of the state."
Joyce has spent the past 18 years on the payer side in New York before joining AHS, and sees the consortium as a way to work with like-minded organizations to share best practices and learn from one another.
He says he sees this partnership not as a vehicle toward consolidation, but as a way to learn from each other—using their own benefit plans as proving grounds—to lead the transition from fee-for-service to a more value-based reimbursement environment.
The consortium has sent out requests for proposals and expects to get bids throughout the spring. It will make a decision on a third-party administrator by late May. Open enrollment in the new plan will take place in the fall.
Direct contracting deals between hospitals and health systems and employers are becoming more attractive as employers become more sophisticated about where the costs lie in healthcare.
Seattle's Virginia Mason Medical Center, a multispecialty group practice of more than 470 physicians, has been working directly with employers to provide specific health interventions since at least 2004.
At that time, Robert Mecklenburg, MD, medical director of the Virginia Mason Center for Healthcare Solutions, met with employers frustrated by the high cost and uncertain quality of the healthcare they purchased from Virginia Mason and others.
That initial meeting eventually led to Virginia Mason's focus on contracting with employers directly for episodes of care.
Although making this change at Virginia Mason was far from an easy journey, the program has grown, focusing on particular bundles of care related to specific conditions, such as low back pain/spinal, total joint replacement, and cardiac surgeries, along with determining whether surgery is appropriate for the patient.
Walmart, the state of Washington, and Lowe's are among the large employers who encourage patients to seek treatment at Virginia Mason by waiving all copays and coinsurance for their employees.
Don't cut out the middleman. Do determine appropriateness of care.
At Virginia Mason's core, the strategy of direct contracting with employers was not born of the idea of cutting out the health insurer middleman, but in determining best practices and appropriateness of a given healthcare intervention, says Suzanne Anderson, president of Virginia Mason Medical Center.
"We do not advocate that we need to disintermediate the payers as a strategy. I think though, some of the first to market have had to do that to get to the other side," she says. "Walmart had to do that and hired a different firm to manage that benefit, but what was more important was the wake-up call."
Payers, says Mecklenburg, are burdened by a legacy of fee-for-service.
Paying for healthcare in such a way naturally leads to paying for interventions that are "two-thirds good healthcare and one-third not-so-good," he says.
He continues: "Their task is to get out of this payment model that they have inherited, as we inherited physicians practicing in their own style. We had to understand the allure of defining best practice and executing on that. [Employers] have to get beyond this benefits mentality and into the purchasing model mentality."
Mecklenburg and Anderson have four tips for healthcare organizations that also want to get off that carousel.
1. Create a culture focused on quality and continuous improvement
Culture change is only possible by developing a long-term vision for your organization to deliver healthcare that is reliable, predictable, and has consistently good outcomes. There's no silver bullet, says Anderson.
"You have to start on the journey and create a culture that embraces climbing that hill," she says. "We have our Virginia Mason production system, and it's really how we empower everyone around for continuous improvement. The product it produces is a best practice pathway created by doctors for patients and employers. It requires a systems-based approach. It doesn't and won't come from federal regulations or health plans."
2. Believe that quality equals value
Part of Virginia Mason's strategic plan is to be the quality leader and to transform healthcare. Virginia Mason thinks quality can be expressed best in an equation as follows:
Quality = Appropriateness x (Outcomes + Service)
"Appropriateness is the hidden secret," says Anderson. "There's a lot of waste because of inappropriate care."
For example, she says, Virginia Mason has demonstrated that nearly 58% of patients who have been referred to their organization for spinal fusion by an outside surgeon really do not need it.
"They did not meet the appropriateness standards," she says. "When you use these methods, you weed out unnecessary care. You can do that analysis with many surgeries. Variation in medical practice is such that in those cases, physicians inadvertently do not add value."
3. Embrace transparency and data
Anderson says the foundation of Virginia Mason's ability to draw large employers to its system is transparency and data help physicians change the way they practice, based on appropriateness of care and likely good outcomes.
It's also how they're able to offerguaranteesof good outcomes to their employer customers in areas such as joint replacement surgery.
4. Create partnerships and collaborations with key people and organizations that help advance quality
When Virginia Mason was first contracting with Walmart, Walmart's executive team told Virginia Mason that the company didn't want to spend a dime less on care than it was already spending, but that it wanted to spend money on healthcare that was highly likely to bring about positive outcomes, says Anderson.
That was a revelation to Virginia Mason's team, who knew they could deliver on that.
Even if Virginia Mason rejected invasive interventions such as back surgery based on predictive modeling, it could make up that loss by serving a larger population with guaranteed good outcomes based on data, says Mecklenburg.
"Volumes don't suffer, because more people are sent here," he says.
A surge of large-scale healthcare mergers suggest the calculus and goals may have changed within the healthcare industry.
This article first appeared in the March/April 2018 issue of HealthLeaders magazine.
Today's mergers are less a play on market domination and negotiating leverage with health plans, and more of a bid for vertical integration and development of a high-value provider network.
Several sizeable healthcare mergers have been announced over the past year. Dignity Health and Catholic Health Initiatives signed a definitive agreement as 2017 closed. Chicago-based Advocate Health Care plans to merge with Milwaukee's Aurora Health Care.
Even Seattle's Providence St. Joseph Health, which was created by a major merger announced just 18 months ago, has been rumored to be in talks with Ascension Health about a merger that would dwarf all other hospital-centric mergers announced recently.
Research suggests that despite the claims of the organizations involved, multistate healthcare mergers often result in higher costs for healthcare purchasers and do little to improve care, although an American Hospital Association–funded research study disputes that conclusion.
But regardless of what the research states, or the vagaries of markets and geographies, a surge of announced and completed consolidations continue to tout cost and care quality as their deal's chief benefits.
The healthcare industry may not have a great record of providing lower costs and higher quality thanks to mergers, but that record looks somewhat better if viewed through a lens of higher margins and back-office economies of scale.
That said, prior deals may have little bearing on the benefits or costs of future mergers, because the nature of healthcare M&A seems to be changing.
Hospital companies aren't the only ones seeking to disrupt. Insurer Aetna, after being blocked from merging with another insurer, Humana, is trying a different tack by merging with CVS, blurring the lines of what type of business it's in.
UnitedHealth Group, another company long identified as an insurer, has been diversifying its business lines for years, notably with its purchase of DaVita's physician group.
While healthcare M&A is more common than it used to be, many of the reasons for it haven't changed that much. Those that participate in mergers still cite scale and leverage as top benefits. But the nature of competition is changing, as bright lines between healthcare businesses become blurred by what some are calling asymmetric competition.
Negotiating leverage still key
Chris Stanley, MD, a former system vice president of population health at CHI and now a director in Navigant's healthcare consulting practice, says until two or three years ago, many hospital or health system mergers were horizontal—primarily built on the theory that "if we're larger in size and have more hospitals, we have more negotiating clout against payers and, as we see Medicare and Medicaid payments dropping off, we'll just be able to ratchet up on commercial rates."
But that strategy has often not played out well for a variety of reasons, from FTC challenges to difficulties with cultural assimilation. "So, the intent has shifted to the idea of gaining operational efficiencies that will save us from having to duplicate IT systems, compliance or legal, or central administrative overhead," he says.
"The idea was if we're bigger and badder, we'll be able to extract more money out of the finite pie that is healthcare spending. That is ending. It's not completely ended, but it will end."
For example, do CHI and Dignity need two central offices, two billing operations, or two supply chains? Indeed, their plans upon the merger are to combine many of those functions, although both CEOs will be retained, as stated in their joint press release when the merger was announced.
While not commenting specifically on the CHI-Dignity merger, Stanley says such savings can be ephemeral, especially if the timeline extends longer than planned. "Where we've seen that be a real fallacy of intent is that you only get that efficiency and cost savings if you aggressively integrate not only all your facilities but your central offices within a year or two of the merger being final."
Mark Armstrong, vice president of consulting operations with Quorum Health Resources, says the opportunity to gain scale and leverage with payers is still a powerful force in merger activity, especially ones where hospital-centric organizations are combining.
"The consolidations that seem most logical are those that are market-based where the strategy is to gain market clout," he says. "Those are the ones that are most often successful. Those that struggle and often fail are where both parties are coming together from positions of weakness. They're losing money, have inferior market scale, but together they're just a larger loss."
Armstrong distinguishes these two merger types by calling them either defensive or offensive, and says both have an opportunity to reduce overhead in billing, supply chain, and other areas. However, negotiating leverage with payers is a key attribute.
"The reality is the vast majority of healthcare services are still fee-for-service," Stanley says. "So, until the tipping point is reached for alternative payment models, capitation, bundles, and true pay-for-value programs, hospitals and physician practices are a business, and the business model right now calls for maximizing volume over value."
Blair Childs, senior vice president of public affairs with Premier Inc., a Charlotte, North Carolina–based company that uses data to improve efficiency and quality for its mainly hospital and health system members, says that while market-centric horizontal mergers haven't gone away and won't for some time, increased FTC pressure in recent years to block such mergers has had an effect—and this pressure likely isn't going to decrease under the Trump administration.
> Negotiating leverage is still key
> Asymmetric competition efforts help with patient "stickiness"
> Get closer to the patient
"This administration is more skeptical of hospital consolidation than virtually any preceding administration," says Steven Valentine, Premier's vice president of strategy and advisory consulting practice. "It just means that organizations have to make a distinction between whether their mergers are truly for market power or for care improvement."
"Some will still try to merge for more market control, but most organizations are seeing the future of competition, and that's in high-value provider networks," says Childs.
Richard Afable, MD, who until December 2017 was president and CEO of St. Joseph Hoag Health in Irvine, California, and who led the 2013 merger that created that health system, says the industry is going through a transition where mergers for market power and payer leverage will eventually fall out of favor.
"The idea was if we're bigger and badder, we'll be able to extract more money out of the finite pie that is healthcare spending," he says. "That is ending. It's not completely ended, but it will end."
Afable and Childs refer to what's coming as asymmetric competition, typified by recent merger announcements such as Aetna and CVS, Humana and Kindred Health, and even mergers that on their face seem hospital-centric—such as Advocate-Aurora, which offers a clinically integrated network, postacute offerings, and a pharmacy network.
The effort, broadly, is to get stickiness with the patient, in that all of the patient's healthcare needs can be met by one organization. "These are about scale and vertical integration and a high-value provider network," Childs says. "Everyone's trying to get close to the ability to engage and get the patient in your network."
Rod Hochman, MD, president and CEO of Renton, Washington–based Providence St. Joseph Health, says each merger is different and can't easily be placed into a vertical or horizontal bucket. More critically, it's difficult to generalize whether a consolidation will ultimately save money for patients or increase quality measures.
As chair of the Catholic Health Association and with a seat on the American Hospital Association's board, Hochman says he's read the research papers on the topic, and notes that much of their conclusions depend on how their data is formatted and which organizations are included and excluded. That doesn't make it easy to determine whether such mergers benefit the patient in terms of quality and cost.
"There are examples of those who have done it well and those who haven't," he says. "Like all things in healthcare, whether the mergers work as their architects describe their benefits is dependent on whom you talk to."
Hochman says he's been through about 30 mergers over his 40-year career in healthcare, and the secret to success in making scale matter is developing a specific game plan ahead of time on how the architects will decrease costs and gain efficiency.
"It's unfair to put all of that burden on just the one issue of hospital and health system mergers," he says. "In the issue of cost and affordability, a lot of people and organizations—not just hospitals and health systems—have their hands in that pot."
In 2017, he says, Providence St. Joseph saved $110 million in costs over what the two organizations would have experienced separately. Much of those savings came from services, supply chain, clinical excellence, and IT. "Scale gets you a platform to reduce variability, and as a physician, this is important to me," he says.
As for plans to possibly grow larger in a merger with Ascension or any other organization, Hochman says Providence St. Joseph is sustainable where it is. "What we're going to look at is asymmetric growth in terms of nontraditional partners—we have one such partnership with Walgreens—and expand that way," he says. "When there are opportunities for other health systems to join with us and where it makes sense to both of us, we'll do those too, but we're comfortable with the size and scope of the organization today."
Getting closer to the patient
Many health systems have moved on from the idea that market share alone will determine a successful future. Instead, it's only a part of the calculus that will go into future consolidations, and perhaps a less important part as time goes on.
Premier's Childs points out the major factor, as he sees it, exemplified in the proposed combination of Humana and Kindred Healthcare. The two Louisville, Kentucky–based companies will split Kindred into home health and long-term care divisions.
Humana will receive 40% ownership of the home health division, the larger of the two, in a deal that will likely close summer 2019, and have no financial interest in the long-term care division. Humana has an option to buy the remaining 60% of the home health division at the end of the third year.
"That's where a lot of healthcare is moving, more toward managing patients in the home," says Childs. "This is … about reducing cost."
Valentine says other major mergers announced recently also reflect the race to capture, engage, and satisfy the patient, rather than physicians, health insurers, or employers.
"When a lot of our members talk about this, they don't talk about discharging patients from their facilities," he says. "They talk about creating a relationship, and that's the way they need to be thinking."
The challenge is still in legacy issues, where if an organization reduces spending, it doesn't always gain the benefit of the savings. This is changing the nature of acquisitions and mergers so that organizations feel they need to offer most, if not all, services a patient is likely to require.
" 'Share of care' is what I like to call it," says Afable, who now serves on the executive committee of the Board of Regents for the World Physicians Organization and is an advisor for Concierge Key Health, a mobile application offering on-demand access to elite physicians and care facilities.
Only about half of what is spent in healthcare is for the work physicians and hospitals do, he says. "Everything else—insurance and behavioral modification, for example—are outside that world, but hospitals and docs can add to that," he says.
Many vertical mergers are focusing on what Afable calls convergence. "They're trying to converge on the customer from different directions, not to create leverage but to address multiple needs in multiple ways, which many believe will allow them to create more efficient models that get the benefits of approaching the consumer from multiple directions," he says. "The jury's still out whether this can be a truly beneficial and sustainable model."
"If we just wanted a huge top line, we could go and acquire and merge and make [revenue] numbers quite big, but we want to do it in a way that's sustainable for the populations we serve."
Marc Harrison, MD, president and CEO of Intermountain Healthcare based in Salt Lake City, says Intermountain is already doing that kind of work through its owned health plan and trying to grow organically, in hopes that work might be replicable across the country, whether through mergers or otherwise.
"Those projects allow us to test replicability and will let us know if we're a health system that can generalize across the country," he says. "Some of our digital and distance health is now in five to six western states in hospitals we don't own, and they achieve outstanding results in standardizing clinical care and keeping people in their home area."
The health system delivers about a hundred clinical services virtually, and in the near future, it will formalize those services into what Harrison calls a virtual hospital.
"We're not quick to do M&A activity unless it would bring us a whole new population we could uniquely serve," he says. "If we just wanted a huge top line, we could go and acquire and merge and make [revenue] numbers quite big, but we want to do it in a way that's sustainable for the populations we serve."
Navigant's Stanley says hospitals are looking at how they can expand potential patient services not only in primary care but in other points of contact, such as telehealth, retail clinics, and urgent care. "It represents a broader reach upstream for patients," he says. "How much services are leaking out, and how much can they retain or keep?"
With margins compressing and only 25% of hospitals in the black, rigorous processes must form the backbone for strategic decision-making, says a health system chief strategy officer.
For today's hospitals and health systems, competition isn't limited to similar organizations. Disruptors range from rapidly consolidating multistate health systems to employers and even Amazon. But smaller, regional health systems can still compete in an era of compressing margins.
Effective competitiveness starts at the top, where a visionary CEO and an ambitious C-suite take advantage of what assets they do have. Instilling a culture of growth is easy to articulate but tough to execute, says Matthew Gibson, PhD, senior vice president and chief strategy officer at Erlanger Health System in Chattanooga, Tennessee.
Gibson, who came aboard Erlanger in September 2017, says he joined the organization chiefly because of its culture of growth, which has contributed to a near doubling of the system's revenues, from $600 million only four years ago to nearly $1 billion. Only eight years ago, Erlanger was an organization whose future seemed somewhat gloomy as it struggled under a mountain of charity care costs.
"This organization has made a lot of progress from eight years ago," says Gibson. "That was when the organization was in a lot of turmoil and there was some question of whether it was going to continue. I'm new, but the team has doubled net revenue in the past four years and now we have our first out-of-state hospital in Murphy, North Carolina."
President and CEO Kevin Spiegel, who took over five years ago, and the board, felt that despite recent progress, future independence was not guaranteed—a stated goal for the board.
Gibson is the first to hold the chief strategy officer role at the organization, where he continues the culture of growth Spiegel created by integrating data and analytics into its strategic decision-making. His experience at academic medical centers, investor-owned hospitals, and a large multistate nonprofit health system will help inform his work, he says.
"Diversity of experience can serve folks in this role well," he says. "I know what works and what doesn't work."
Chief strategy officers can provide a critical voice to guide the health system in driving volume and value in a time of enormous change, says Adriane Willig, a consultant with Oak Brook, Illinois–based Witt/Kieffer, and an expert on strategy officer executive searches.
"The CSO is not necessarily charged with operationalizing a strategy, but with full execution and making adjustments," she says.
Gibson says he's focused on three strategies that have grown the culture of growth at Erlanger:
1. Multiple access channels
Erlanger is in the process of developing a new primary care strategy to build out its primary care network and more fully integrate the health system into the decisions patients make outside the acute care space, says Gibson.
Erlanger is also building out its affiliate network with smaller hospitals in the region, offering them GPO savings through Epic connect, which allows the hub—in this case Erlanger—to extend its Epic EMR license to affiliate "spokes." It's also helping those smaller affiliate hospitals with physician recruiting, building out EMS services, service line programming, and managing the hospital, which can extend to joint venturing or even direct ownership by Erlanger, if the local board desires that.
"We want them to connect with us at the points they want to connect," he says.
2. No-regret moves
Gibson says Erlanger is developing its culture of growth by focusing on what he calls "no- regret" moves—those that will likely work regardless of a value- or volume-focused environment. Risk hasn't penetrated its region to any significant degree yet, but Erlanger plans to be ready. It started its first foray into risk: a narrow commercial network ACO with Cigna, in January, and is a member of the Vanderbilt Health Affiliated Network, a large Tennessee clinically integrated network.
It's also on the verge of rolling out its primary care access strategy, which focuses on multiple access channels, which Gibson calls "a first for our market."
"Risk hasn't really evolved here, and that's an important consideration for any strategy officer," he says. "We've been telling everyone for at least the past five years that risk is coming but, the reality is, it just hasn't happened. It's an important litmus test for leaders in roles like this to know the pace toward risk and what makes sense."
3. Build on strengths
All of Erlanger's primary care practices are medical home–certified, and it's building more low-cost ambulatory capabilities to get further into the low-acuity side of the local healthcare market. Gibson says it's critical to build out the continuum because Erlanger has the advantage of being the low-cost provider in the market despite also owning the area's teaching hospital function.
Erlanger is partnering with Teladoc to launch telemedicine capabilities in May as part of its access strategy. It will provide on-demand low-acuity access for basic primary care services. That will allow patients to access Erlanger doctors not only during off-hours but will push access to outlying communities from Chattanooga.
The strategy is intended to enhance referrals to partner hospitals in outlying areas, says Gibson. Balancing volume within the network can provide a virtuous circle to prevent the main fear of every hospital Erlanger seeks to partner with: that Erlanger wants to supplement its volume by taking procedures away from local facilities.
"It doesn't do us any good as a super-regional to funnel everything back to the mothership," says Gibson. "With our Level I trauma center, we have major capacity challenges here."
Erlanger's acquisition of Murphy Medical Center is a perfect example, he says.
"We want to keep more there because it's contrary to our margins to bring low-acuity stuff here, and it's better for the community to keep it there," he says.
Despite the Murphy acquisition, Gibson says Erlanger's growth ambitions have their limits. His prior experience has shown him there's a sweet spot in terms of the right size of a health system. Erlanger's current size offers payers and patients a lot of value.
"When you look at aggregate data, bigger isn't always better," he says. "There's not much impact on quality outcomes, although you get some economies of scale. We're actually more attractive because our rates are lower. We don't have to merge with someone else."
A vendor portal left an Indiana health system vulnerable to a cyberattack. Its CEO decided to pay the cyberattack ransom. Here's why, and what he wants other leaders to know.
It's breach season.
That's what Ron Pelletier, founding partner of Pondurance, a cybersecurity company based in Indianapolis, calls February through April. Partly, that's because it's also tax season, when a lot of financial information is being sent and received via the internet. Bad actors often spend the latter part of the previous year "weaponizing" their tools and doing reconnaissance. Then they look for vulnerabilities.
For Hancock Health in Greenfield, Indiana, just outside Indianapolis, breach season started a little early. About 9:30 p.m. on the night of January 11, Steve Long, its president and CEO, got a call from the health system's IT staff, telling him a computer in the lab was infected with ransomware. In an abundance of caution, the IT staff had turned everything off that was connected to the internet.
They were too late.
The attack from a criminal syndicate in Eastern Europe was initiated through the emergency backup facility used by the 71-staffed-bed hospital many miles away, and it had infected many, if not all its servers. The SamSam ransomware did not affect patient life-support systems.
Unlike ransomware programs that depend on phishing tactics to trick employees to open an infected email, the SamSam attack is more sophisticated. The criminals found a vulnerable port set up by one of the hospital's vendors, then located a password to gain entry into the system, Long says. They infected data files associated with the hospitals' most critical information systems.
"It was a port you had to log into but it was exposed to the internet," Long says.
Long hopes by sharing his story that other healthcare organizations will avoid the disruptions that Hancock Regional experienced. He's even written a publicly accessible blog about it.
From a forensics investigation done later, it appears the criminals made attempts at a "brute force" attack, in which they ran through tens of thousands of potential password combinations to gain entry.
"That did not work, but at some point, they found a login and password from a vendor who was working with our IT systems," says Long. "We probably will never know exactly how they got a login and password. We're told all the time we should be prepared for such things. We had hired a company that was supposed to track this, and had anti-malware and antivirus software we thought was good."
In short, Long says, Hancock Health probably had a false sense of security about its network.
Long decided to pay the ransom price of four bitcoin, about $50,000 at the time, to begin the recovery process. After about 70 hours offline, and little sleep for the IT staff, communication systems were restored, network file servers were brought back online, and the electronic medical record system was restored.
Long and his staff emerged scarred, but smarter. He says other CEOs should learn at least four lessons from his headaches:
Remote Desktop Protocol ports need multifactor authentication
The vulnerability the criminals took advantage of at Hancock is a common port associated with Windows that has plenty of legitimate uses, says Pelletier, such as remote system maintenance, but ports like that are often exploited.
"With this particular port, if clients have a business case that it needs to be open we advise multifactor authentication, including a password, a biometric, and a PIN, randomly generated," he says.
You're more vulnerable than you think
"In terms of readiness, we had systems in place, had a company that was supposedly monitoring us, and we had cyberinsurance," says Long.
Hancock didn't use the cheapest vendors, but not the most expensive, either.
"When you're the [CEO], IT is the thing you always feel like you put so much money into," he says. "What we've also learned is you could have the best of everything, and you're not 100% safe. There is a balance."
It takes humans to counter humans
Software can't fully do the job. It takes humans to offer a dynamic defense to the ingenuity of a hardworking criminal enterprise.
"A lot of organizations buy into what vendors say about their tool but there are vulnerabilities we don't know about and someone might be harvesting that," says Pelletier. "Bad actors leave evidence of their attempts that can show something is going on, but it takes a human to do the analysis."
"In cyber terms, if you are targeted, then with enough time, effort, and resources, they will likely be successful, but It takes time and resources and money," says Pelletier. "If you make yourself a hard target, they'll move to someone else who is more vulnerable."
Don't underestimate the criminals
Cybercriminals carefully calibrate the ransom they ask for based on your organization's ability to pay, Pelletier says.
"They want to get paid and that's why the [ransom] dollar amounts, relatively speaking, are low," Pelletier says.
He says you can restore from a backup rather than pay the ransom, but the likelihood of being able to recover completely may be questionable.
Adds Long: "They force you down a path. We needed to get up quickly, and we had some question about whether our backups were viable," he says. "I agree with every reason not to pay, but until you are faced with the decision, it's easy to say lots of things. For us it made the most sense to get the decryption keys."
Long says such things can happen to anyone. You have to plan for the worst.
"I never imagined I would be sitting there on a Thursday night having shut down all our computers," Long says. "We want others to learn from this and we believe we can be, for lack of a better word, a beacon."
Two hospitals have demonstrably cut length of stay and improved survivorship among the most vulnerable of patients. Meanwhile, they've increased capacity and improved care.
Anyone who doubts that clinicians can create a virtuous circle of lower costs and improved quality needs to look at the results two hospitals in California and Tennessee have achieved by changing drug and care protocols for their ICU patients.
At its most basic, the change in care protocols involves incorporating evidence that greater use of narcotic pain medications and less use of benzodiazepines in the ICU improves outcomes.
Further, getting patients off sedation, assisted breathing, and up and moving more quickly can cut not only length of stay, but also can improve long-lasting negative effects on patient functionality and even survival.
"More and more data and research shows that some of the meds and treatment strategies used in the ICU contribute to longer stays and delirium," says Krista L. Kaups, MD, director of the surgical ICU at 909-licensed bed Community Regional Medical Center in Fresno, California. "The [medical] community thought long stays and delirium was no big deal for a long time—that's just something that happens with such patients. But those factors have long-lasting effects on patients' ability to recover functionality six months or a year out, so clearly we needed to change our strategies."
Community Regional is one of 77 hospitals that participated in the ICU ABCDEF Bundle Liberation Collaborative organized by the Society of Critical Care Medicine, based on recommendations about the use of ventilators, pain medication, and clinical practices in the ICU that have shown progress in cutting lengths of stay and improving outcomes among ICU trauma patients.
Results of the collaborative, which ran from August 2015 until June 2017, were published in late summer 2017.
Managing pain and sedation
For years, clinicians were trained to keep patients comfortable and sedated, even frequently in medically-induced comas in the critical care unit, says Jeff Wright, MD, medical director of critical care at 800-bed Baptist Memorial Hospital in Memphis, which also participated in the Collaborative.
"But we learned that's probably more dangerous for patients, so we started looking at how to minimize and improve that," Wright says.
One way to improve patient recovery times is to limit the use of benzodiazepine medications, which can contribute to delirium, in favor of narcotic pain management medications, he says.
"We have changed the pain management order set," he says. "How we think about managing pain has changed, with the nursing staff making sure they're adequately assessing people's pain while at the same time helping them get functional."
To help assess pain, the patient must be awake, so if, for example, a patient whose breathing is ventilator-assisted does not have a significant brain injury, respiratory therapists will give them a trial of breathing on their own, says Kaups.
"We have decreased use of benzodiazepines significantly, so our sedation medications are less likely to cause delirium, and we also have changed vent days, which have gradually decreased as has our length of stay," she says.
Mobility and exercise ASAP
Mobility and exercise is also extremely important in improving outcomes and cutting ICU length of stay, says Kaups.
"Even if they have rib fractures and pulmonary contusions, we're going to have them sit up—there's no reason they can't with help and have them get up and walk," she says, noting that even someone who is completely healthy will lose 10% of their muscle strength each day they spend in bed.
"If we don't, they'll see significant amounts of muscle mass loss," she says. "And the more we get people up and moving, the better they do from a delirium standpoint."
As part of rebuilding the pain medication order sets, Baptist's electronic medical record for ICU patients was modified to make sedation goals more prominent for nurses, as well as modifying care protocols to provide nurses and therapists cohesive and coherent guidelines about getting people out of beds, says Wright.
Emphasis on collaboration
Because so many clinicians interact with ICU patients, teamwork and a cohesive strategy to change protocols is paramount.
Wright says 45–50 people were involved in the collaborative. Over the course of its participation, Baptist reduced hospital length of stay by about a day, increased overall likelihood of survival by 15%, and reduced the time when patients were in a coma by a similarly dramatic amount, Wright says.
He was most surprised by the increase in survival rate, but says the incorporation of daily multidisciplinary rounds checking on patients "to the point of being boring—every patient, every day—is what it takes," he says.
Wright says that more than 200 nurses had to be trained in a common language and order sets, working together with a core team of physical, occupational, and respiratory therapists.
Wright says about changing care protocols in the ICU: "My advice is go in with an open mind and expect it will take months or years to get it working as well as you want it to, but there's been a dramatic change in how we manage these patients," he says. "Before, if you went in the ICU during the day, most patients used to be asleep. Now they're awake."
Additionally, he says the hospital experienced cost savings of about $800,000 in its first year.
"We didn't hire anyone extra for this project, but I've proposed downstream that we need some more FTEs from the physical and occupational therapy side to get things where we need to be."
Kaups says in addition to better patient outcomes, Community Regional has improved its ability to serve its community.
"We're a Level 1 trauma center and we're always at capacity, so of course it has cost implications," she says. "We're looking at bed capacity and the ability to provide beds when we need them. Anything we can do to decrease length of stay from an economic standpoint is great."
Premier Inc. published a report in late 2017 focusing on ICU trends based on inpatient data from 20 million patient discharges across 786 hospitals over a five-year period (2011-2016).
Patients treated at top-performing hospitals spent 24% less time in the ICU, and the healthcare improvement company said in the same report that with the right tactics, ICU stays within this five-year period could have been reduced by nearly 200,000 days annually. The top 10 ICU diagnoses with the highest variation are as follows:
Sepsis patients with major complications or comorbidities: 187,584 potentially fewer ICU days
Infectious and parasitic diseases associated with operating room procedures, and major complications or comorbidities: 147,369
Cardiac valve and other major cardiothoracic procedures without cardiac catheterization, but with major complications or comorbidities: 121,953
Coronary bypass without cardiac catheterization, but with major complications or comorbidities: 97,422
Respiratory system diagnosis with ventilator support for up to 96 hours: 94,201
Craniotomy and endovascular intracranial procedures with major complications or comorbidities: 88,663
Sepsis patients using a mechanical ventilator >96 hours: 67,464
Cardiac valve and other major cardiothoracic procedure with cardiac catheterization and major complications or comorbidities: 63,521
Cardiac valve and other major cardiothoracic procedure without a cardiac catheterization, but with complications or comorbidities: 60,583
Heart failure and shock with major complications or comorbidities: 59,351
Quality of care and teamwork across the care continuum have taken on a new level of importance as a variety of structures, from ACOs to readmission rates, force outcomes-based financial accountability on hospitals and health systems.
Post-acute care organizations and the quality of care patients receive there have become such important issues to inpatient-focused organizations that they’re keeping score.
Beth Weagraff, corporate vice president of post-acute strategy and implementation, says developing a scoring system for skilled nursing facilities and home health companies used by the 46-hospital, nine-state health system helps focus Adventist on the fact that it’s on a path toward delivering “holistic” care that includes patient interactions with inpatient, outpatient, post-acute, and the physician office.
“We see holistic care as our differentiator, but we recognize that if we’re going to expand the network and improve the product, we’re never going to have enough post-acute assets to do that ourselves,” she says.
Yet among its nine states and 82,000 employees, Adventist does own significant such assets. While following patient choice protocols, the system refers patients to both owned and non-owned post-acute providers, in varying volumes, depending on the city, state, or region where it has a presence.
That means it needed a fair way to recommend options for where patients should continue their care following an inpatient discharge, which is where Weagraff and her colleagues sought help to develop a survey and scoring system to refine and incentivize post-acute network partners.
Quantifying quality and cooperation
In late 2016, Adventist began to work with a consultant to begin to construct a framework that incorporated quantitative and qualitative metrics to rank post-acute partners in a way that was agnostic as to whether the partner was an Adventist-owned asset.
CMS star ratings are among the data points, as are individual partners’ readmission rates and variation and improvement on patient outcomes. Scoring well on these criteria qualified that organization for a site visit for further evaluation.
What constitutes “scoring well,” varies from market to market depending on the supply of potential partners, says Weagraff. For example, in Texas, where thousands of home health care agencies exist, thousands were screened off the eventual recommended list, but in rural markets in Florida, not many were eliminated at this stage.
“Once we kind of weed them out through quantitative criteria, a trained team goes out and conducts site visits for those that are still in the running,” she says.
Questionnaire prior to visit
A work group that spans all Adventist markets developed a questionnaire that helped score providers on a set of variables, such as new patient capacity, administrative staff, clinical staff, capabilities, types of technology, the organization’s willingness to partner, and other categories.
The questionnaire totals 35-40 questions, and a few are market-specific, such as hurricane readiness in Florida.
“It’s been an evolution, but it provides a broader picture of their approach to patient care that you don’t get in overall star ratings,” says Casey Silver, Adventist’s director of business development for post-acute care.
The questionnaire results help the work group measure actual quality, which is paired with the perception of quality as evidenced by the site visit.
“We’re enabling and providing tool set to sustain the network,” says Weagraff. “Casey works with them to model the criteria for the network so that we can continue to build the relationship with partners over the long haul.”
During the site visit, the team focuses on putting together collaborative forums at the local level with designated post-acute leaders in the region, to evaluate over time how post-acute providers are performing in quality outcomes and in responsiveness.
“Those are the key components of what deployment looks like,” Weagraff says.
Adventist has completed the first two processes in three Florida regions: South, Central, and North; and it will roll out all 12 networks by the end of 2018. During the next two years, Adventist teams will help focus them on collaboration with Adventist hospitals.
Weagraff says post-acute partners have been eager to try to compete for inclusion in the network.
“Key is going to be how we sustain and continue to evolve the network,” she says. “We’ve gotten very good engagement so far. It’s been good dialogue.”
Weagraff says that in developing such a system, one can’t assume what a team of Adventist care managers (it employs more than 2,000 of them), region to region, knows about how to deal with patient choice on post-acute providers. Patients can choose to continue their care wherever they like, regardless of any survey, ranking system or quality scores, and Adventist managers provide patients a full list of providers, not just the ones that score well enough to be in its preferred provider network. But they also spend a lot of time and effort to educate care managers about the importance of these choices.
They also make use of vast amounts of data in the ranking system. NaviHealth, a data management and clinical decision support company, helps educate Adventist care managers on utilizing such data.
In training care managers, Weagraff says, “what became important was to set legal boundaries first. Here are the guardrails. What’s been interesting is in some cases you can have collisions between physicians and the patient.”
That said, the focus has been on forming the network.
“We know how we’re going to measure it,” she says. “Providers have to understand they’ve got to earn referrals based on responsiveness, delivering on strong outcomes, CMS measures, ensuring patients are happy with their experience and that they are responding quickly to our requests to send patients.”
She says for other health systems, ensuring that owned post-acute assets are performing at the top of their game is important because of the agnostic nature of the network.
Also, health systems should “be open to forging relationships with post-acute providers that you may not have known were in the market,” she says.
Having a consulting firm with experience in setting up such networks provides objectivity, she says, adding that while Navigant is no longer involved in the program, the firm helped set up a framework and helped Adventist avoid internal politics in the process.
“We’re on a journey to provide top-decile performance, so sometimes you need someone else to provide industry best practices,” she says. “They’ve worked with 40 health systems. If they get it set up, you can sustain it. That way if we ask them to come back and validate, it keeps their objectivity as well.
The new BPCI Advanced bundled payment model means those who invested in the former mandatory bundles didn't throw their money down the drain.
When the Centers for Medicare & Medicaid Services cancelled or scaled back its mandatory bundled payment models last year, many healthcare providers feared the investments they made to prepare for these models might be wasted.
But there's plenty to like about the new voluntary Bundled Payments for Care Improvement (BPCI) Advanced model for organizations that had invested in value-based care models.
In BPCI Advanced, participants will be expected to redesign care delivery to keep Medicare expenditures within a defined budget while maintaining or improving performance on seven specific quality measures, says Tobin Lassen, chief knowledge officer with Global Healthcare Alliance in Houston, which has experience helping hospitals, health systems, and physicians manage bundled contracts with both commercial and government payer sources.
The quality measures, the first two of which apply to all clinical episodes (the others are for specific ones) are:
All-cause hospital readmissions
Advanced care plan
Perioperative care: Selection of prophylactic antibiotic: First or second generation Cephalosporin
Hospital-level risk-standardized complication rate following elective primary total hip arthroplasty and/or Total knee arthroplasty
Hospital 30-Day, all-cause, risk-standardized mortality rate following coronary artery bypass graft surgery
Excess days in acute care after hospitalization for acute myocardial infarction
AHRQ patient safety indicators
Participants bear financial risk, have payments under the model tied to quality performance, and are required to use electronic health record technology that passes CMS certification.
Meeting those requirements qualifies the model as an Advanced APM, which is significant, at least partially, because physicians who participate in one will be exempt from MIPS reporting requirements.
"The 32 types of clinical episodes in BPCI Advanced add outpatient episodes to the inpatient episodes that were offered in the Innovation Center's previous bundled payment model (the Bundled Payments for Care Improvement initiative), including percutaneous coronary intervention, cardiac defibrillator, and back and neck except spinal fusion," according to CMS' website.
Going forward, it will be important for such programs to create and monitor the measures they track, says Lassen.
"CMS has seven quality indicators in this. Your organization will be judged on them, and your bonus will be contingent on them, not just on the cost," he says.
The new voluntary bundles can pay off for five reasons, he says:
1. Investments haven't been wasted
The introduction of the new BPCI Advanced model underscores that those who have already made an investment did not throw their money down the drain, says Lassen. The introduction of specific voluntary bundles means those who want to move further down the risk curve can do so, and at their own pace.
"A lot of people made a lot of investments and none of that goes to waste," says Lassen. "You can continue to deploy that capital."
That means investments in outpatient care networks or integrated electronic medical records, or team-based healthcare, such as multidisciplinary rounding to identify gaps in care that may lengthen stays, could still deliver ROI, if the organization is willing to take on risk through the voluntary advanced payment models.
2. Comprehensive bundles
Lassen advocates applying for and participating in a comprehensive and diversified group of bundles instead of just cherry-picking high-risk conditions.
That includes adding outpatient bundles, which represent three of the 32 available bundles under BPCI Advanced, and helps an organization move more quickly from a largely fee-for-service model to a value-based one.
"I wish there were more [bundles]," he says. "This expands program size and allows for opportunities for equal or better outcomes in the less expensive settings. Also, we see a lot more hospital-payer-physician relationships centered on those outcomes."
3. Physician involvement
The new bundle offers opportunities for physicians to get involved, a critical constituency to making bundling work, says Lassen, based on his commercial bundling experience. The BPCI Advanced bundles are not just hospital-driven or convener-driven.
"Now, nonconvener groups, including physician groups, can bear or apportion risk," he says. "What's so good about it is that not being hospital-driven, physicians can choose whether to be aligned with the hospitals, because they really control the care. It's never been that way, so physicians should be very happy."
4. No MIPS!
Although a certain portion of their work must be in the advanced model to get the bonus, now that physicians can participate in upside and downside risk through BPCI Advanced, they will not have to do MIPS reporting.
Lassen says looking at total investments required to do the MIPS reporting and Medicare adjustments through 2026, he's not so sure MIPS offers a good risk-return probability anyway.
"They don't have to worry about that if they participate in BPCI Advanced models," he says.
5. Better patient engagement
The BPCI Advanced program is based on patient-centered care, navigation, and transparency, says Lassen.
"When we do our direct-to-employer bundled programs, we lead patient participation through that whole process, and it's key for [clients], because it can get quite complex. You need to be able to navigate the patients through it."
Focus on outcomes
One issue with the new voluntary program is that performance measures are still largely process-oriented, he says, as opposed to true outcome measures that create value for the patient.
Some of the commercial bundles Lassen has experience with are more outcomes-based, and he predicts BPCI Advanced or its successors will migrate toward that goal over time.
As an example of the power of outcomes-based measurement, one commercial bundling program Lassen worked with included the use of a provider-created database that tracked multiple participants for spinal procedures for three years, following outcomes.
"At this point, based on that database, they can predict the likelihood of success for a spinal intervention procedure," he says. "That's where we're heading on the commercial side—especially those who can track this data over time with that level of sophistication."
The BPCI Advanced portal closes March 12, so those who want to participate will have to decide their risk appetite and apply quickly, Lassen says.
The next application period won't start until January 2020.