Just a few updates before I get coffee.
First an interesting paper looking at surgical performance as a function of concentration on certain procedures instead of sheer volume of procedures**:
For all four cardiovascular procedures and two out of four cancer resections, a surgeon’s degree of specialization was a significant predictor of operative mortality independent of the number of times he or she performed that procedure: carotid endarterectomy (relative risk reduction between bottom and top quarter of surgeons 28%, 95% confidence interval 0% to 48%); coronary artery bypass grafting (15%, 4% to 25%); valve replacement (46%, 37% to 53%); abdominal aortic aneurysm repair (42%, 29% to 53%); lung resection (28%, 5% to 46%); and cystectomy (41%, 8% to 63%). In five procedures (carotid endarterectomy, valve replacement, lung resection, cystectomy, and esophagectomy), the relative risk reduction from surgeon specialization was greater than that from surgeon volume for that specific procedure. Furthermore, surgeon specialization accounted for 9% (coronary artery bypass grafting) to 100% (cystectomy) of the relative risk reduction otherwise attributable to volume in that specific procedure.
The argument this paper makes is that surgeons who are mainly doing one thing are better at that one thing than if they are doing lots of different things even if the total volume count on a given surgery is the same.
Intuitively, this makes sense. A surgeon who is only doing one thing can recognize at an intuitive level when something is odd and adjust or correct before there is a crisis.
Now the other payment reform piece is the Medicare bundles for cardiac care and extending hip fracture bundles:
During a conference call with members of the media, Patrick Conway, MD, Acting Principal Deputy Administrator and Chief Medical Officer at the Centers for Medicare and Medicaid Services (CMS), described three policies included in the proposal:
New bundled payment models for cardiac care and the extension of the joint model to include treatment for hip and femur fractures A new model to increase cardiac rehabilitation A proposed pathway for clinicians and physicians in bundled payment models to qualify for payment incentives under the Medicare Access and CHIP Reauthorization Act Under the proposed cardiac-care bundled payments, hospitals would receive quality-adjusted pricing for heart attack and bypass episodes of care, including 90 days after a hospital inpatient stay, according to a CMS factsheet.
What this is telling me is that the combination of bundled payments and quality accrual due to specialization is that the general surgeon and the general specialist will be declining in importance. Instead, hospitals will have emergency departments that can handle stabilization of patients and then they’ll ship the patients out to county or regional centers of excellence. If someone has a broken hip, there will be two or three hospitals in a metro area with a dozen surgeons who just do hips and nothing else. If there is a need to do a bypass, a hospital will have two bypass surgeons who do 90% of those procedures between the two of them.
If thees results hold and if these policy changes continue to accumulate where payments are based on quality of the entire episode of care, I don’t know what the general community hospital looks like in fifteen years. It won’t be a one stop shop for 90% of a town’s needs. The quality and two sided risk arrangements won’t allow that financially.
** BMJ 2016;354:i3571 accessed 7/27/2016