Innovations in Neurosurgical Practice, Part II: Quality Measures

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- Hello ladies and gentlemen, thank you for joining us again. This is part two of a discussion regarding neurosurgical practice management and innovative models for running departments of neurosurgery. I'm really honored to have with us, Dong Kim. Dong has been one of the, if not the most, innovative and progressive neurosurgical chairmans in the country, and his results show that. And that's what's most important. I think he has demonstrated very clearly that we need new leadership, new style of leadership in order to be able to fight the fierce challenges that we've be facing recently, and much more of which is ahead of us. So with that in mind, Dong, I again thank you for being with us, and please go ahead with these topics.

- Thank you so much Aaron, I appreciate it. So in part two we're going to continue talking about some of the approaches that we take here. And I want to go over in some detail this idea of the service line, which you've all heard about it. Everybody has a service line. Most of it doesn't function at all, and we've had an approach to this service line that I think is different. So it is the idea that for any one disease entity, you're going to have a executive, or a group, or a group of physicians that will develop programs, increase volumes, work equality, strategy, capital allocation and so on. There are lots of obstacles to having an effective service line, as you probably know. When you have different hospitals, even in one system that are supposedly working for the same system, they can often be competing. You have many different physicians in different silos. Administrators and physicians may not always work well together. And probably the biggest problem that I've seen is that service line administrators often don't have much control over budgets and capital allocations. So while they're trying to get things done, really, they don't have much power. So we developed an approach to the service line, because this was part of my job when I came here as a neuroscience director, and it currently involves our MNA doctors that I described in the last part. We're about 66 faculty, and about 130 providers if you include the residents, fellows and EPPs. UT Neurology, who is our partner there are about 23 clinical faculty, and about 30 faculty total. Now, they focus on multi-specialty or sub-specialty neurology care in a medical center. And we, in the MNA, do most of the neurology in the system and then we also have a few independent physicians. So that's our service line. There's several things that's helped us. One, is that we have one administrative leader, Amanda Spielman, and myself. And Amanda also runs our physician group, the MNAs. Our service line is integrated. And then the end result of that, because we have such large number of physicians, is that once we decide to do something, or we decide that certain kinds of surgeries should only be done at this hospital or that hospital, that becomes a de facto decision for the system, because we control all of the doctors. And that's the leverage we have to make the service line work. We didn't realize that starting out, that's just how it ended up. Of course we get senior, the CEO, on down all their buy-in before we implement these strategies. And we have a governance council that I mentioned to go over it, but the physician group ends up controlling a lot of what happens for us. 'Cause these are some examples of specific projects that I'm going to go over, and what we do. So one of my jobs was to develop a program and increase the volume, and we showed some volume data earlier. Then I divide that into neurogen and transfer programs. For emergencies you need very advanced capability. And we have the only level-one trauma center. There's another county-run facility in Houston, Comprehensive Stroke Center all ready. Now we started realizing, as big as Houston is, we can't bring every patient to one location, especially because we started having lots of capacity issues in the medical center, despite the fact that we run 141 neuroscience beds. So we developed the extended capability, geographic distribution model that we've implemented. We've also used telemedicine to help them lock in emergency for us providing telemedicine services to emergency rooms across the region. And we wanted to be the provider of choice because we have the depth and breadth of services and everything that you need to run a medical base. So this is our current map of the different hospitals. And if you look at the bottom, it shows you all the different services that are available. We have one coronary center, three other centers with prolonged neurosurgery call. They are all going to be CSC as I described And two of them will be level two trauma centers as well. And then smaller areas where they do spine surgery. And just like our clinics being geographically diverse, this is very helpful for us, not only to gain market share and provide services where patients are, but this kind of coverage becomes critical in contractual decisions with insurers with discussions. Because then they know that their patients are going to be at one of our facilities, if they don't have a contract with us. They value us because of this kind of emergency coverage that we provide. We've been in discussion with a joint commission now for almost a year to set up a single system of what they're gonna call it, Integrated Stroke Center System. It will be the first one in the country. This is a new designation that was developed at our suggestion. And they're coming in for a final site visit in February that should be done in March. The idea is that if you have a system like this with 16 hospitals, you don't need to maintain endovascular capability for aneurisms or aneurism equipment at all 16 places. In fact there should probably, certain things only be done at one place. But if your hospital doesn't have a CSC designation and a competing hospital gets a easier BNB designation, and now there this traffic changes, with all kinds of implications. So our system model has two locations that can do everything so we can always accept the patient, but we also have locations where only conducted, or acute care will be provided. And it's a comprehensive rational system to providing stroke care, which I think will be very useful for other systems in the national opening. So we started a telemedicine program jointly with UT neurology and we wanted to make sure we provide a good service, but keep these emergency cases coming to our system. So you can see the program has grown enormously. Everybody's proud of these emergency rooms, have about a 25% PPA treatment rate, which is quite good. We've now extended it over here onto a ICU telemedicine program and then also onto a outpatient telemedicine outreach program. So here's a service time project that we did where we were having many transfer denials. The programs got successful and they were getting more transfer requests. So we accepted about 2,500 patients about two years ago. But believe it or not we had over 900 requests that were not fulfilled. So this is something you can only do with a service line. But what we decided was to create what we call a rapid transfer program. So we wanted a phone call to come in to the TMC, requesting a transfer, and depending on the acuity of the patient and the situation, that situation, we wanted to be able to send them to two or three of our other hospitals. If you remember the prior map, the tertiary centers with the blue could accept these patients. So that's part of the reason for creating that. we have independent rural critical care neurology and neurosurgery call-up for those locations. So our transfer program worked out a situation where the doctor receiving the phone call at the TMC will make the decision where the patient will go, without any questions asked or other phone calls, not to an administrator or one of our partners. The patient will end up in the designated place. And as we started building up at the TMC, we will triage more lower-level patients to other locations. We created what's called a leavening document that showed which kind of cases could be treated at each location and a significant expansion of our ICU came as a result. Now currently, around 70-ish ICU beds across the system, and in the next two years, that's gonna be 90 neuroICU beds. And this was a result of our transfer program, in the 12 months that it started, we've been able to divert over 700 patients to two hospitals. And as this happened, our total transfer volume actually increased, and even requests by 23%. So as we became more available, we had more requests than we did before. And currently we're accepting between 350 or 400 transfers a month, at all of our locations combined. And this is something what do could be as a service line, this data show where we are, and the denial rates going down compared to what it was when we started the program. So the key to that was all of us as partners working together, trusting each other, accepting patients within multiple phone calls. Now on the elective side, I think that's been the area of our greatest growth significantly more than on the emergency side. I think having the best doctors is the most important ingredient. But we also have a very patient-centric approach. For example, when a patient with a brain tumor comes to see me, they see the neuro-oncologist and the radiation oncologist at the same visit, no matter what. We just have a clinic together, and vehicles that we can all go into each other's rooms if necessary. We do that with pain management, for example, and it's fine. And as we are already a fairly dominant local referral group we're now very interested in national and regional referrals. And our regional strategy is going to involve significant outpatient telemedicine availability in places like where native or where local people could potentially come in for surgery that might not have access to a neurosurgeon. I'm gonna go over the COE program a little bit. And this has been our collective referral growth at each of our different campuses. That has been on expansion of our program. So I don't know how many of you are familiar with the Walmart's center of excellence program in spine. I think it's been in existence for almost 10 years and we joined it recently. It's currently five centers. And it's a comprehensive approach where you get a patient's medical record. These are patients that have been recommended for surgery locally. We review them here, then if they need a visit or a surgery, then they fly in and then we take care of the patient until they fly out. That's the COE model. It's also a bundled payment program because you get one set price for taking care of that patient. And many people think that it's a discount. For us we became a COE without a discount. I think those financial things, I probably shouldn't talk about. But the COE program works well for several reasons. If you're Walmart, what you find is that, let's say for every X number of patients that have been recommended for spine surgery, a significant portion of patients don't get response to the group, they come to a COE. This is the same thing that happens with Cleveland Clinic with the heart, for example. And then of the surgeries that actually do happen, another significant portion is a smaller, less big surgery than what was recommended locally. So for the employer, by having better indications, first of all, there's a significant savings. The second thing is that the COE is supposed to get better results, shorter length of stays, quicker return to work, fewer disabled patients, and so on. Then Walmart will tell you that when they started the program, this was a voluntary program for their workers. And then they started putting in incentives to go to COEs. As they've collected data, they have found that the patients do so much better in a COE, that now, or recently, it's become that they're out of network if they don't go to that COE. And that's a significant change. And to what Aaron was asking me earlier about if we're doing a really great job? And if the costs were low? In this kind of model, the entire cost from the doctor, to the hospital, to what happens in the OR, goes into one bucket. And as a result, if parts of that are little lower, other parts of it can definitely be higher. I think there is a clear incentive to only have the best service and the best results and in a model like this. What would you think about that, Aaron? That kind of makes sense, right?

- That's what they're asking us. That's what the government wants. They want a bundled payment APM model, Alternative Payment Models where you really have a center of excellence that has high volume, lower variability, as set principle of operations in any system. So if you run a high volume, and low variability, and control four variables and evaluate results, this is as basic as it can get in any operation that goes on in this world, even a simple process. And I think that's what the Surgeons of Excellence are capitalizing on, and I suspect that's going to be the future. I just don't see any way around it.

- Yeah. And I'm excited about this kind of program. It's gone very well for us. Despite Harvey having come in about a month or two after starting, we've kept the momentum going, and we're going to start a second COE and PBGH in January. And as part of this too, we've started a long-term outcome program where we're asking patients, as a baseline, to fill out these standardized forms. We do it through a computerized digital portal, so they don't have to come in, and we try to get the data for three, and six, and 12 months after. And we piloted this in my own clinic. We don't know what's good or bad. We're just trying to get some of this data, but you can see that there are clear differences before, and one year after surgery, and as we'd get more outcomes data, I think this will help us quite a bit. So I would say that for program building, both conducted and acute cases, it depends really on having the best doctors and the best service, but also the right geographic reach and infrastructure to go along with that. And that's where the partnership and joint strategy with the hospital is so important. For us, the service line works because our administrative team and the physician leadership work together, and because the physicians provide so much of the service that when we say this is what we're going to do, that becomes a strategy for the hospital system. Of course, we engage all the local CEOs to make sure they're happy with it, but we don't get stymied with lots of obstacles with people with competing interests. A focus on quality, I think becomes the basis for local and national referrals going forward. And I think that efficiency of cost structure and superior outcomes will not only allow us to grow, but allow us to take care of each other and do good in one good operation. So with that, our last topic is home management of the ACOs. And I think all of you have heard about ACOs. I don't know how many in here students are involved. I was fairly involved in our ACO, and I have some thoughts on how it's going to affect us and if there are other relations as well for me. This is a kind of an overview of what a co-management structure is, and what happened with us. I even set up part one. We have moved a little away from co management side, so I decided not to spend most time on it, and only focused on ACOs. So I have a whole talk on the history of ACOs and so on. It's just not as interesting, but I wanna specifically talk about the Memorial Hermann ACO. And most ACOs in the country or in the MSSP, or the Shared Savings Program. So these are some of the requirements. ACO has to have an independent board. That has to include practicing physicians and one Medicare representative, and that was on the inaugural board of our ACO. The ACO then applies and gets approval from CMS. And really all you do as an ACO, initially, is to define a roster of primary care patients, and primary care physicians. And our initial roster here was 22,000 patients, and now about 30,000. But if you multiply that by $10 to $12,000 per year, per Medicare beneficiary, that budget for those patients is truly giganteus. It's about hundreds and millions of dollars. You have to require quality data. And then the CMS does all the work of calculating what actually happened on the backend by themselves. They take your 22,000 initial patients and say, "They totally spent this many Medicare dollars." In Houston, or the Southeast region or whatever their comparison group is, it's this many dollars on average that was spent. And if there's a negative Delta, CMS will return half of that to your ACO as a bonus for the performance. So that's the scheme of MSSP. In the initial period, and this will change at some point, there's no negative risk. So if you spend a lot more than the average, then you don't pay a penalty. There's no reason not to do this. Memorial Hermann both wanted that experience and felt that they might get something good out of it, like bonus payments. And we'll see what happens with that. So to do this, you need a primary care network that's on one common eMR platform, where you can't be able to see them 'cause you'd better build the quality, if you ever join in a specific way. That has to go on. And then you have to have committees that work on care improvement. So these were the goals that that MHACO set. It started it, and this was the result from the first year. I am not exactly sure how it happened, but nationally, the MHACO was considered the number one ACO in terms of cost savings. I think it's just got to be that Houston or the Southeast region is a more expensive area. I can tell you, having been involved with this, there was no management of these patients. There was no specific ACO screening, or something different. It was just a network of primary care physicians. So the idea, though, is when you have cost consequences, that the ACOs will naturally start to manage the patients at some point. This was year one. We have to report quality data. It came out, and pretty good as well. And in year two, it was just as much. And it was an interesting situation where our ACO got a 30-some million dollar check after a year from the federal government, for doing this. And then you have to think, "Well, where are those monies got to go?" It's good problems to have. But we had no plan or scheme for any of it, really. So what about the neurosurgeon and the specialist? I think this is a big question. And maybe I'll talk to you about where an ACO's got to go. So currently, there are rules that a primary care doctor can only join ACO but a neurosurgeon can be involved with as many ACOs as he or she wants. The reason for that is that people didn't want to mandate specifically for all relationships. However, I think these are the three phases that an ACO will go through as they start to try to manage one. First, they'll encourage their primary care doctors to use better service, or have better results or more careful in their indications. These specialists are still going to be paid on a fee-for-service basis. So currently in our ACO, I get a referral, I submitted bill to Medicare, and I get paid at the same rate. But as the ACOs evolve, and different ACOs are at different stages, the next stage will be that they'll decide they're gonna hire a few specialist, working with them entirely to help manage their issues. The first one are likely to be high volume, high cost, diabetes management, heart, lung failure, and so on. And finally, it's going to involve specialists, and specialists are gonna end up having to, I think, be in one type of ACO. That's my guess, as to what's going to happen. I think that a neurosurgeon will have a very important role in the ACO because spine care is very expensive, and everybody knows that. And we increasingly perform that, here at Memorial Hermann. When I started we had 30% spine share versus 70% for ortho. Now that's flipped around. In Houston, we're doing 25% of all the spine surgery. So that's a large turnaround. So that will be important. And because of the financial performance of any ACO is dependent on overall patient spending, the quality of our practice, especially if we take care of trauma patients, subarachnoids hemorrhage, all that, will be very important. Here, we were a very early participant at. For example, our spinal implant model, was a thing that other services like ortho and heart took, and we provided significant leadership in increasing the collaboration between the physicians and the hospital. And because of that, we also took the lead in developing the service line concept. I think, having been involved in this, nobody really knows what these should be. Nobody knows how the money should flow, or how they should be regulated as well, and the best way to effect it, is to be in the leadership. as I call it, have a seat at the table, and it will effect happens at your local ACO. The thing also that's interesting, is CMS does not mandate what should happen when the dollars come in, or how the ACOs should be run. So there was a lot of flexibility and autonomy locally. So from this, I think we learned that there are significant shared savings that are possible. Now, I think that's going to diminish over time, and that's part of CMS's strategy, is, I think, when it starts try save money, we're going to have the baselines to decrease and we're gonna have to do even better, but maybe that's the nature of the world, as they say. If you're not running faster and getting further ahead, you're falling behind. The focus so far has been on primary care networks. But that's going to change, I think, to include more specialists. And I do think that these kinds of paradigms are an opportunity. I think if you are a decreased utilization doctor and a higher outcome doctor, you should get paid much more. Overall, not just for that case than for somebody who's not getting those kinds of results. And there are mechanisms coming in where even if those aren't overall, for example, if you're a hospital-employed physician, and the administrators are looking all these data about you, I think it's going to influence their decisions. That's another reason why I think that being in a physician group, where we manage it ourselves, and we decide what we get paid, and so on, is much better and at least something I'd even tolerate. So in summary, I think this is a time of change and opportunities. There's risks. Definitely the speed, and extent of change will vary regionally. But I think we all see this happening wherever we are. Fee-for-service will not disappear, but it will become less important. Even with all the macro nips, the likelihood is that reimbursements are going to decline. AND I think we're going to need to look at other kinds of financial models. Quality and value metrics will pick on greater and greater importance. I think it's important to get ahead of it and do well. I think long-term outcomes are gonna become just as important, and smaller boots are going to decrease in size. I hope I've shown you that there are many options available and different things that can occur. And that I think what's important is to have a significant win-win situations with your institution and other partners. Now, I want everybody to keep a few things in mind. I'm so privileged to have gone into neurosurgery and it will remain an honor, and I am very optimistic about the future. We are going to retain significant leverage. We just have to use it in the right way and focus on our mission as the best way to do it. Maybe we can think differently about things, but being proactive is the best way to effect what happens for you locally. We need to maintain our basic values, and I think no matter what comes we are well positioned to thrive. On the last slide, I don't have much to say. If you're a new graduate, here's just some advice for you, if you can read it, but I think their future is very bright. And also, the innovations in our practice and new treatments for nephroblastoma, and thrombectomy for stroke, and it's a very exciting time to be in our field. So thank you, Aaron. I'd appreciate any other thoughts or questions from you, and it was great to be able to do this.

- It was an honor. Thank you so much, Dong. You're definitely thinking ahead. I think, as I've always said again and again, in these two sessions, you're one of the most forward thinking people who takes on challenges, not starting dealing them with them as adversaries, but as opportunities. and you have used opportunities within challenges to succeed. And that's something, unfortunately, many other programs have not. This is sort of a difficult topic to discuss, but it's a personal opinion that I wanna inject here. Traditionally, neurosurgical leaders were academicians who wrote a lot of papers, had NIH grants, and therefore based on their academic impressions nationally were able to find the chairmanship and leadership positions. I think that traditional idea of a well NIH funded leader to be a chairman of a program is challengeable. I don't think those are not necessarily those leaders that are gonna succeed at best. I think the new generation of neurosurgical leaders are those who are very apt in business, in understanding healthcare models, in terms of running service lines, and in terms of finding the opportunities within a market that is almost trying to reach a free market regulation status. You're truly trying to create a free market model within the healthcare system. That competition will drive costs down. Those models that have not really... They do not share much with running a laboratory, necessarily writing grants, although those are very important, are not necessarily the qualifications for a neurosurgical leader to run a system and work in a system that competition for cost and quality drive the ultimate success. What are your thoughts there?

- Well, I think that first academic mission is very important. I brought up that for a long time, during that, and I certainly, that I have had NIH clients, and so on and I just got it all along. So I think that's an important part of it. But this is a different world too. And I agree with you that we can't just have a skill set of how to get to that next level. And I also think, having been around the country, there are some institutions that are very set, they're strong academic institutions, their departments have been defined a long time and their values and needs are different, and maybe the opportunities or the requirement to do a lot of things is different too. Now, I didn't come here thinking that I was going to do this or that, I just saw it as an opportunity to build a program. And in doing so, I felt like I needed to do this and that, and these kinds of things happen. I think definitely, though, the trend, and you've alluded to this, that I see, even sitting on such committees here over the last 10 years for chairs, I don't think that, if the research, or having a large publication, that the teaching experience is any less valued, but definitely the ability to show that you've worked in any administrative leadership goal. And it could be a small role, one unit or whatever it is, and understanding some of the healthcare changes has become just as important as that chair-leading too. I think it's just become as important. I think different areas will require different kinds of leaders, but definitely this is a skill set, and like you're getting an MBA, that there other neurosurgeons doing that. I think that will help out too, quite a bit, going forward.

- Again. Thank you, Dong, for a superb discussion.

- Thank you so much. Thank you, Aaron.

- You're welcome.

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