Becker's Spine Review

27 Thought Leadership No regrets about dropping bundled payments, president of Rothman Orthopaedic Institute says By Carly Behm A lthough Philadelphia-based Rothman Orthopaedics has eliminated bundled payments, its president, Alexander Vaccaro, MD, PhD, said using them is still worth it for some practices. He reflected on that decision a year later and told Becker's Spine Review how he thinks other practices should look at the payments. Question: At a Becker's event last year, you announced that Rothman was dropping out of bundled payments. Has your view of bundled payments changed over the past year? Dr. Alexander Vaccaro: My view of bundle payments has not changed. It is an effective way of developing patient-facing value-based healthcare decisions. The innate problem, how- ever, is the intrinsic "race to the bottom" effect of bundled payments that reduces long-term reimbursements to import- ant stakeholders in the process. This, unfortunately, misaligns incentives to participate. I have not seen any material changes in the approach from CMS that would make continued par- ticipation in the BPCI program compelling. At Rothman, we are proud to deliver the highest quality care, and affordability is part of our mission statement. We believe a commitment to increased value in healthcare should be rewarded for the long-term, not just in the short term for initial savings. Q: What would you advise other practices to consider when it comes to bundled payments? AV: Every practice circumstance is unique. I think it is extreme- ly important to engage in the process of bundled payments to understand where a particular group is in their value prop- osition to patient-facing care. The ability to manage risk in re- imbursement requires sophisticated data analytics, alignment among all stakeholders and the operational resources to navi- gate patients through evidence-based care pathways. Q: What other value-based models do you see develop- ing in orthopedics? AV: As practices become more sophisticated in their ability to manage risk, there will be a natural shift toward capturing premium dollars in the form of sub-capitation agreements. These arrangements may be with health systems, cccount- able care organizations, large primary care groups or any en- tity that is involved with Medicare direct contracting. Consid- erations for carve-outs, such as for spine procedures where there is greater variability, would need to be factored in to ensure financial viability and maintain high quality patient outcomes. Q: How will the payer market in Florida influence Roth- man's operations? AV: We will focus on delivering evidence-based, cost-effec- tive care to local communities in the Florida market which is easily accessible so that we can exceed the expectations of our patients. n CMS, payers among the major obstacles to outpatient spine, Dr. David Essig says By Carly Behm CMS poses a primary obstacle to outpatient spine migration, according to David Essig, MD, of Northwell Health in New Hyde Park, N.Y. He told Becker's Spine Review about the biggest roadblocks he sees with outpatient spine surgery. Question: What billing challenges pose the biggest threat to outpatient spine migration? Dr. David Essig: Migration to the outpatient surgical space provides unique opportunities in spine surgery. While spine sur- geries typically represent around a quarter of orthopedic surgeries, they do represent nearly half the profits in many instances. Some of the challenges with regards to billing will involve the pre-authorization process. However, with some of the updated CMS rules, pre-authorization is not needed for certain codes. Furthermore, CMS has updated their inpatient only list allowing for the migration of more cases to the outpatient centers. Other challenges involve cost sharing agreements with major carriers. Whether these involve bundled payment agreements or other episodic care agreements will depend upon the strengths and resources of the outpatient centers. n

• Cover