Becker's ASC Review

73 ORTHOPEDICS No regrets about dropping bundled payments, Rothman Orthopaedics President Dr. Alexander Vaccaro says By Carly Behm A lthough Philadelphia-based Rothman Orthopae- dics decided a year ago to eliminate bundled payments, its president, Alexander Vaccaro, MD, PhD, said they are valuable for some practices. He reflected on that decision a year later and told Beck- er's Spine Review how he thinks other practices should look at the payments. Question: At a Becker's event last year, you an- nounced 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, however, is the intrinsic "race to the bottom" effect of bundled payments that reduces long-term re- imbursements to important 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 participation 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 extremely important to engage in the process of bundled payments to understand where a particular group is in their value proposition to patient-facing care. The ability to manage risk in reimbursement requires sophisticated data analytics, alignment among all stakeholders and the operational resources to navigate patients through evidence-based care pathways. Q: What other value-based models do you see devel- oping 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, accountable care organizations, large primary care groups or any entity that is involved with Medicare direct contracting. Considerations 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 Rothman's operations? AV: We will focus on delivering evidence-based cost- effective care to local communities in the Florida market which is easily accessible so that we can exceed the expectations of our patients. n compression without destabilizing the spine and decompressing nerve roots and obviate the need from doing any interbody graing and fusion. You are preserving most of the normal anatomy with very minimal blood loss, much lower risk of infection and way faster recovery. Most importantly, you're not burning any bridges with this approach. ese surgeries all can be done outpatient and most of them going home the same day. I also think robotic spine surgery — just like how robotics advanced in urology and other general surgery procedures — is go- ing to continue to advance in spine, where I can potentially see where the robot is performing the endoscopic decompression, performing precise osteotomy cuts and plac- ing pedicle screws. However, I would be very wary about advertising laser spine surgery as it does not have a big consensus for good outcomes or advertising minimally invasive procedures as nails and a hammer where every single surgery can be done that way. Not every decompression or fusion can be done as minimally invasive. Unfortu- nately, there's recently more bad results of spinal deformity surgery that are being done minimally invasive with suboptimal outcomes that require a major revision reconstruction. ere will always be spinal deformity cases that should be done with a traditional open approach. Brian Gantwerker, MD. e Craniospi- nal Center of Los Angeles: By looking backward, we can see that very few MIS technologies have completely phased out. ere are technologies that perhaps have not had their moment as of yet. I have seen some companies with innovative solu- tions, for instance for interbody constructs, especially stand-alone transforaminal lumbar interbody devices that probably need two to three more revisions as well as peer-reviewed studies conducted to properly select patients. e fad technologies can oen be found in the dustbin of the last 20 years. And perhaps not justifiably so. Not to name names, but we can all give examples of things we really miss and liked that have been relegated to the elephant graveyard. I think you can predict the ones that will endure are technologies that make you work faster or do something you already do in a novel, faster or safer manner. John Burleson, MD. Hughston Clinic Orthopaedics (Nashville, Tenn.): I think endoscopic spine surgery might finally be ready to make it. ose utilizing this technique are more enthusiastic than in the past and the technology to support it has expanded. As with most technologies, I be- lieve the real key to new technology sticking is their utilization at teaching programs. As more residents and fellows are exposed to endoscopic spine surgery, they will perform these procedures from the beginning. n

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