Raising the Standard: Destination Care as a Model of Employer Value-based Healthcare, Part 2

| October 1, 2019

by Anthony T. Petrick, MD, FACS, FASMBS, and Dominick Gadaleta, MD, FACS, FASMBS

Dr. Petrick is the Quality Director at Geisinger Surgical Institute and Director of Bariatric and Foregut Surgery for Geisinger Health System in Danville, Pennsylvania. Dr. Gadaleta is Chair of the Department of Surgery at Southside Hospital and Director of Metabolic and Bariatric Surgery at North Shore University Hospital, Northwell Health in Manhasset, New York; and Associate Professor of Surgery at Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York.

Funding: No funding was provided for this article.

Disclosures: The authors reports no conflicts of interest relevant to the content of this article.

Bariatric Times. 2019;16(10):14–15.


This is Part 2 of a two-part Raising the Standard article series that examines destination care as a model of employer value-based healthcare.

“It is not the strongest or most intelligent who will survive but those who can best mange change.” —Charles Darwin

In last month’s column, we explored the differences between medical tourism and destination care (DC). Specifically, we examined DC as a model of employer-driven, value-based healthcare and provided a brief history of companies that have implemented this model for their employees. This month, we examine DC models in bariatric surgery, focusing on 1) the selection of a provider site, 2) the required characteristics of a health system to earn a value-based contract, and 3) the evidence that such contracts will lead to lower costs and better outcomes in bariatric surgery.

Cost benefit is not the only incentive for companies to develop DC programs; rather, these companies are seeking better treatment outcomes for their employees, in addition to financial benefits. Companies seek value both as payers and for their patients. Remember that Value=Quality/Cost. Walmart is the largest private employer in the world, providing healthcare coverage to over 1.1 million employees and their families.1 Walmart employees live in every state, providing incentive to regionalize DC centers to optimize travel costs and access to care. Like other companies, Walmart recognizes that healthy employees are more productive. Evidence-based outcomes data demonstrating that bariatric surgery improves employee health and productivity and reduces long-term medical costs align well with these industry objectives.

Companies with DC programs target potential DC centers by first reviewing publicly available data and their own employee outcomes and costs at the center. Once potential centers are identified, provider level data are then reviewed. This includes information not only on surgeons, medical, dietary, and behavioral specialists, but also info regarding the role of trainees and mid-level providers in the healthcare system. Health systems that earn DC bariatric contracts must have a history of providing healthcare value. Characteristics of such centers include the following:

  • Strong quality indicators at the provider and system level
  • A track record of evidence-based, integrated care delivery
  • A commitment to patient-centered, collaborative decision-making
  • The willingness to participate in “bundled care” bariatric pricing—centers with experience in bundled pricing are better positioned.

Providers relying on the fee-for-service reimbursement model to maintain a contribution margin are often skeptical of the financial risks associated with bundled care. While these concerns are well-founded in centers without the characteristics outlined above, there are significant benefits to participation in DC programs. These programs produce a “halo effect,” improving care delivery for all bariatric patients. Elements of bariatric program care pathways are often applied to procedures outside of the DC bariatric program. Participation requires a significant work effort to understand and manage costs, as well as to assure consistent outcomes. However, once centers attain reliable cost and outcomes data, they are well-positioned to manage both, thus creating additional opportunity for payers and patients. Furthermore, these programs create a national footprint for centers, which can improve recruitment of local and regional payers, patients, and providers.

Initial efforts to develop bariatric DC pathways recognized that the bariatric surgery patients present unique challenges compared to those in Walmart’s DC programs for cardiac, spine and joint surgery. Severe comorbid disease is the norm in bariatric surgery patients. Assessment of nutritional risks and their management is essential to a bariatric DC program. Also, both short- and long-term complications more often require surgical management and medical expertise that might not be readily available in a patient’s hometown. Walmart’s previous DC pathways were built on a model in which patients were evaluated and underwent surgery in a single trip. The unique risk factors seen in bariatric patients necessitated a two-trip model for DC. Patient travel for an initial evaluation and then telemedicine encounters are utilized to provide medical, dietary, and behavioral care in preparation for surgery. The interval between Trip 1 and surgery is driven by patient factors rather than the payer.

The bariatric DC program at Geisinger began in December 2016. Patients were offered either Roux-en-Y gastric bypass (RYGB, n=40) or sleeve gastrectomy (SG, n=23). During the first 18 months of the program, we treated patients from more than 20 states (Figure 1). A comparison of DC patients to all other bariatric patients treated in our medical center revealed that the DC patients were at higher risk within all demographic metrics, including age, sex, body mass index (BMI), and comorbidities. Outcomes data that will be presented at ObesityWeek 2019 demonstrates there was no difference in any 30-day clinical outcome, with no mortalities between DC bariatric patients and the other bariatric patients treated in our medical center. Additionally, 100 percent of DC patients had follow-up at six months with total body weight loss (TBWL) of 27.6 percent (RYGB) and 23.3 percent (SG), respectively.

Walmart now has seven DC bariatric centers across the United States. The bariatric benefit initially required that patients have diabetes and a BMI greater than 40kg/m2, but now it follows National Institutes of Health (NIH) criteria. Over 300 patients have undergone bariatric surgery in the program. About 75 percent of the patients were women, with a mean age of 46 and BMI of 50kg/m2. At nine months postoperation, Walmart’s medication costs had fallen by 73 percent and overall healthcare costs by 54 percent.1 In the near future, we hope to share Walmart’s data on employee productivity and absenteeism after bariatric surgery.

The number of companies considering DC models for their employees’ healthcare is growing. Centers for Medicare and Medicaid Services (CMS) is expanding bundled care reimbursement penalties and bonuses determined by clinical outcomes. Bariatric providers can prepare for this new healthcare environment by understanding and optimizing their costs and clinical outcomes.

References

  1. Woods L, Slotkin JR, Coleman MR. How employers are fixing health care. Mar 2018. Harvard Business Review site. https://hbr.org/cover-story/2019/03/how-employers-are-fixing-health-care. Accessed 2 Oct 2019.

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