Raising the Standard: ProvenCare® Bariatric: The Influence of Team-based Care on the Value Equation in Healthcare

| November 1, 2018

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

This column is dedicated to highlighting a broad range of quality issues in bariatric surgery.

Dr. Petrick is Quality Director, Geisinger Surgical Institute; Director of Bariatric and Foregut Surgery, Geisinger Health System, Danville, Pennsylvania. Dr. Gadaleta is Associate Chair, Chief of General Surgery, MBS Director, North Shore University Hospital, Northwell Health, Manhasset, 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. 2018;15(11): 8–9.

“A pessimist sees the difficulty in every opportunity; an optimist sees the opportunity in every difficulty.”

–Winston S. Churchill

In last month’s column, we examined the Geisinger ProvenCare® Bariatric program as a model to underscore the quality benefits of enhanced recovery and team-based care in bariatric surgery. This month, we explore the financial contribution of the program to “value” in healthcare delivery.

The Value Equation in Healthcare: Value= Quality/Cost

The core principal of ProvenCare® Bariatric was to create a culture that expects and insists on elimination of unwarranted variation as a patient-safety issue. This program for Roux-en-Y gastric bypass (RYGB) significantly improved the quality of care by reducing length of stay, readmission rates, and complications.   

While the clinical elements were being developed, a simultaneous process of engagement with Geisinger Health Plan (GHP) specialists was taking place. The records of the most recent 100 GHP patients undergoing RYGB were reviewed. Outliers were excluded, and the cost of care was calculated. All diagnostic related groupings (DRGs) associated with these patients within 90 days of surgery were identified. A panel of bariatric surgeons, obesity medicine specialists, and GHP medical directors conducted a review of DRGs and determined which to include under a bundled reimbursement model. This process was designed to eliminate the “à la carte” approach to reimbursement that results in higher payments to healthcare providers when patients experience complications. The results of these efforts were two bundled payment packages for RYGB—commercial and Medicare. Medicare patients had a higher comorbid disease burden, length of stay, and readmission rate and, were therefore assigned a slightly higher reimbursement.

There were two novel financial elements of the ProvenCare® Bariatric program:

  1. The development of a bundled payment which would cover all care related to the RYGB for 90 days after the procedure
  2. An agreement that cost savings related to readmission would be shared equally between the clinic and GHP

We previously reported that ProvenCare® Bariatric resulted in significant decreases in length of stay, readmissions, and complications with nonsignificant reductions in intensive care unit (ICU) admissions and reoperations. Prior to the implementation of ProvenCare® Bariatrics in 2008, the contribution margin for GHP patients undergoing RYGB was 64 percent. While the contribution margin varied year to year, the mean contribution margin through 2016 was 49 percent. This was a 15-percent decrease but was achieved despite a 23-percent cost increase over the same time period. Furthermore, a significant portion of the cost increase included anesthesia charges related to an initiative to increase the accuracy and efficiency of anesthesia billing in the health system. While this revenue was diverted from the surgical clinic, a significant portion of the 15 percent subsidized a positive contribution margin for the anesthesia clinic.

The program was designed to reward quality improvement process through decreased readmissions. Historically, the mean cost to GHP of a readmission after RYGB was about $10,000. Between 2009 and 2012, GHP saved 12 readmissions compared to readmission rates prior to implementation of ProvenCare® Bariatric. This represented a cost savings of about $120,000. GHP shared half of this savings as a favorable contribution to the surgical clinic budget. The program saved 79 readmissions from all payers during the same time period.

We did not calculate additional cost savings realized through decreased length of stay, ICU utilization, and reoperation if they were not associated with a readmission. However, these savings represent additional health care “value” associated with the ProvenCare® Bariatrics program. Another definition of “value” in healthcare would set the numerator as quality plus patient experience. Patient engagement and education before and after bariatric surgery were core principles of the ProvenCare® Bariatric program that can enhance patient experience.

The ProvenCare® Bariatric program was an experiment within a single health system with the capability to reproduce a reasonable microcosm of our national healthcare model. The experiment engaged both administrators and providers in a large healthcare delivery organization, as well as the health plan and patients. It was only possible because the provider and payer were accountable to a single leadership dedicated to the program. The leadership provided personnel, information technology (IT), and financial resources with no assurance of success. Our bariatric group pushed aggressively to be included because of our confidence in the quality and efficiency of our program that had been modeled by the accreditation standards of both the ACS and ASMBS.

In the 10 years since we launched ProvenCare® Bariatric, the principles of standardization, largely under the umbrella of enhanced recovery, have become a common means to improve surgical quality. However, there has been considerably less movement on the side of cost and reimbursement. Undoubtedly, the opportunities to partner with payers are limited, although we have seen a similar partnership with Blue Cross/Blue Shield and the Michigan collaborative group. The opportunity to leverage the remarkable quality associated with bariatric surgery is the next frontier. We must redefine our relationships and initiate partnerships with payers to provide more access for our patients and lead the healthcare community in solving the current cost crisis in United States healthcare.

Next month: Overview of American College of Surgeons Clinical Congress

References

  1. Petrick AT, Still CD, Wood CG, et al. Feasibility and impact of an evidence-based program for gastric bypass surgery. J Am Coll Surg. 2015;220:855–862.

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Category: Past Articles, Raising the Standard

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