Episode 29 – September 2021: Sharing in Success

BACON Episode 29 Transcript

Julie: This is BACON, brief ACO news from the MaineHealth Accountable Care Organization, a sous vide monthly podcast for health care providers. I'm Julie Grosvenor.

Mike: And I'm Mike Clark. Sous vide.

Julie: Yeah, Mike. It's like sous chef. Sous vide.

Mike: Sous vide. Alright, well, Julie and I are practicing physicians and aspiring chefs and liaisons with the MaineHealth ACO.

Julie: That's right. And in this episode, we're going to introduce you to a Maine med orthopedic surgeon who is taking hand surgery out of the operating room.

Mike: Yes, but first, the ACO's chief operating officer, Shannon Banks, joins us here to spread some good news.

Julie: We need some good news!

Mike: We do need some good news. So, Shannon, you're our good news. That will be our Meaty Topic for this month. So grab a fork and knife and let's dig right in. Meaty Topic.

Julie: In an era of not so great news, it's refreshing to share something positive with you.

Mike: Yes. And what we have today is a very positive success story about - wait for it - us.

Julie: What do you mean by us, like you or me?

Mike: Well, yeah, actually, I mean, everybody participating in the MaineHealth ACO. Our listeners, you, me, everyone in the ACO who's worked to improve the value of care for our patients.

Julie: Well, that's a big us. So here to fill us in on that is Shannon Banks, the ACO's chief operating officer. So I'd like to welcome you, Shannon.

Shannon: Hi, Julie. Thanks for having me. Hi, Mike.

Mike: Hi, Shannon. We're so grateful to have you here. So let's dig right in. So as I understand it, one of the markers of success for an ACO is earning shared savings from its value based contracts. So this is a bit of an interesting concept, and I'm hoping you can unpack that a little bit. Can you describe what shared savings really is?

Shannon: Sure, and happy to. It is a complicated concept, but the idea is that every contract in which we participate has cost and quality objectives. And if we are able to hit both cost and quality objectives and we save the system money, then the ACO and its participants get to share in the savings that we've created by hitting both cost and quality objectives. And the shared savings then is, in turn, returned to ACO participants.

Julie: So in a nutshell, we get shared savings if we spend less than anticipated, but our quality is at least as good as the target.

Shannon: That's exactly right, Julie. So if we come in below budgeted targets for spending, but we hit our quality targets, we are able to achieve what's called shared savings.

Julie: So what strategies do we use to get there? How do we do this?

Shannon: Great question. There are three basic drivers of success in these value based contracts. And those include paying close attention to quality. And the ACO works hard to help our participants understand which are the most important quality metrics to attend to and how best to hit those targets. One of our main roles is providing good information to our participants so they know where they are when they're aiming to hit quality targets. We also aim to assist our practitioners with documenting their care accurately, so accurate documentation of the care is important so that we best understand the risk of the patients involved and we're providing a good record of their care. And that also can contribute to hitting our cost and quality targets. And then finally, we care about utilization and appropriate utilization. So making sure we're using our expensive services most appropriately. So, an example where the ACO assists participants here is in our Where to Go for Care campaign, where we aim to educate patients about appropriate use of the emergency department, for instance, and when they might better use a walk in clinic or go see their PCP.

Mike: And Shannon, my understanding is the MaineHealth ACO has earned shared savings in some of their contracts in the past, isn't that correct?

Shannon: We definitely have, Mike. We have been a risk bearing entity for many years now, and we have typically earned shared savings in most years. And very recently, we got some great news that we've achieved shared savings in our largest value-based agreement, which is the Medicare share savings program. And we're happy to let you know that we earned 4.2 million dollars of shared savings.

Mike: Wow. Wow.

Julie: That's fantastic.

Shannon: It's really exciting. And we're excited that that revenue will be, in turn, distributed to our participants.

Julie: That's wonderful news.

Mike: Well, thanks for sharing this great news with us, Shannon, and thank you to you and your whole team for all the work you've done to support our practices, including little practices like mine in being able to participate in this successful contract.

Shannon: Oh, I'm glad to. Glad to be here. Glad to tell you about it. I really think it's important to acknowledge, though, that it's the participants who are doing the hard work here. It's practitioners and their leaders paying attention to the quality metrics and prioritizing accurate documentation and helping our patients to understand how to use the system most effectively and efficiently.

Julie: So in addition to being, you know, financially beneficial to us, it sounds like really it helps the patients as well. It just gets them better, more appropriate care.

Shannon: Absolutely. And we cannot achieve shared savings by reducing utilization alone, for instance. These contracts are set up in such a way that you must pass through the quality gates in order to achieve the shared savings earnings. So it's absolutely critical that we pay attention to the quality metrics, the quality targets and the appropriate documentation of the care we provide.

Mike: So, given the success in the MSSP contract and knowing all the work a lot of us have done on documentation or communicating with patients about appropriate utilization, all the little bits and pieces, you know, controlling A1c, working on CHF, just the myriad efforts that we have done, what's turned out to be some of the key components of our success in achieving shared savings with a Medicare shared savings program?

Shannon: Well, Mike, you're right, those efforts that you describe are important for the MSSP contract, as well as all of our value-based contracts. As we've reviewed the results of the recent MSSP earnings, we have come to appreciate that our results are significantly driven by improvements in coding and accurate documentation, in other words, and also lower than expected utilization compared to both the region and the nation. And I was interested to see that that lower than expected utilization was true even when adjusted for COVID depression of utilization around the nation. So that's very interesting. And it implies to me that our attention to accurate documentation and our attention to helping folks seek the right level of care for their health care needs are paying off for us.

Julie: All right, so we nailed it this year. What do we need to do more of or even better next year?

Shannon: Well, Julie, I think, you know, we certainly saw improved performance and it's exciting to earn 4.2 million dollars and be able to distribute that to our participants. There is a lot more on the table for us, and that is absolutely related to the same three drivers. I would suggest if there's one thing that our participants pay attention to, that it would be accurate documentation of the care they're providing. But again, quality and utilization will continue to be drivers as well.

Julie: Well, thank you, Shannon, for joining us, sharing the news and kind of helping us understand what we've done and what we need to keep doing.

Shannon: Thanks, Julie, and congratulations to you and Mike and all the participants for earning 4.2 million dollars.

Julie: Wonderful. Thank you. The Sizzle. Welcome to The Sizzle, our segment featuring MaineHealth ACO participants doing good things inside or outside of work.

Mike: Yes. And this month, I'm pleased to announce that my esteemed co-host and orthopedic surgeon, Julie Grosvenor, talks to Ross Feller, a fellow orthopedic surgeon at MMC. He's leading an effort to improve the patient experience and reduce the cost of hand surgery by shifting procedures from the operating room to the outpatient setting.

Julie: So first, tell me a little bit about yourself. I know you're a hand surgeon, but tell me, what exactly do you do?

Ross: Yeah. Sure. So I started with MMP orthopedics and sports medicine about three years ago and came on as the first and only hand surgeon with Maine Medical Partners at that time. And so I was tasked with essentially building the hand and upper extremity division at Maine Medical Center, which I've been doing for the last couple of years. And basically, I'm a hand and upper extremity surgeon. I take care of essentially elbow to fingertips in terms of problems. And I've done both an orthopedic trauma fellowship and a hand fellowship, so definitely have a unique interest in trauma and also a unique interest in pediatric and congenital hand surgery. But one thing I'm particularly interested in is cost savings in the health care system, which is probably the reason why I was brought to talk to you about carpal tunnel in the outpatient setting today. But it's been one of the biggest things that I've tried to implement since I got to Maine, because I saw a lot of it in my training, and I saw that the outcomes were just as good as doing it in the OR with similar complication profiles and huge cost savings to the patient and the health care system. So I just felt it was my responsibility, if I was truly going to build something new and innovative here in Maine, that that would be a part of it.

Julie: Yeah, well, that's music to ACO ears, delivering great care at less expense. So I'm very interested to hear more about this. So have you done this elsewhere before?

Ross: Yeah. So particularly when I did my fellowship with the department at the University of Utah in Salt Lake. Essentially, they had set up a system where all of their hand surgeons partook in what we called the treatment room program, where once a week each surgeon was assigned a day to basically do local cases outpatient in essentially what we call a treatment room. So not a formal OR setting where you have an anesthesiologist and the associated equipment that you need for that. But really just getting a room together with very basic supplies and performing these surgeries safely and effectively with equal outcomes. And so I saw that for a year while I was in Utah and was just amazed that they had put together such a good system. They were saving so much money by doing so and not at the expense of patient satisfaction or anything like that. Patients are incredibly happy. And I can echo that in my own experience. But essentially, that was the real driver to do this at Maine Medical Center. I'd like to say that I invented this and I'm like the creator of wide awake outpatient carpal tunnel surgery. But unfortunately, I can't. I mean, this has been done for years. In other places. You look at places like Canada and Europe, where they have more of a socialized medical system, and this is used really pervasively in those kinds of places.

Julie: What did you need to create or do to have a space that was appropriate for this?

Ross: The space doesn't take much. I wish I could take you guys on a tour of our treatment room, but essentially it's no bigger than an exam room. We have a reclining mechanical table in there, but you could use a stretcher or reclining chair of some kind. We have a table that we put the hand on and we have all our equipment in-house to do the surgery. So the space is the most important thing, for starters. And it's not as easy as it sounds because there's a lot of regulations around getting a room approved to be a treatment room. I would say that was the majority of the challenges that we went through in getting this approved. I think the next thing is a good team. That's probably the most important thing beyond anything is having a good team that's on the same page. Essentially, you need a surgeon, an assistant and a kind of a circulator, somebody who is not scrubbed in and doing things like charting or getting extra supplies that are needed during the case or anything like that. But really, you can do this with two or three people very effectively.

Julie: Tell me more about the patients. So is this for everybody, do they all get on board or do you have kind of a mental selection process you're using?

Ross: I think that patients who have issues with anxiety, claustrophobia, things like that are not good for this type of surgery. They should be under sedation in a larger room and a more controlled setting. You know, we talk about the sick patient, you know, the patient with cardiac comorbidities or on anticoagulation or a diabetic. And, you know, one would say, well, this is not the kind of patient that you want to do in a treatment room. And certainly for the first year or so where I was trying to really establish this as a safe and effective process, and it's good, and we got to keep continue growing and doing it, I really limited those patients. But I got to tell you that it's a very good option for a sick patient, somebody who you don't want to put under anesthesia of any kind, whether that be, you know, sedation through an I.V. or general anesthesia. I do have pretty strict criteria for ones with diabetes. I try to get patients below 7.5, which has been demonstrated in the literature to specifically in hand surgery to start seeing exponential increases and complications. So I use that for diabetics. But quite honestly, I mean, if I have a a patient who has bad vascular disease, has had a couple stents and is on anticoagulation, that's actually the kind of person that I want to do under local anesthesia. And again, because we've demonstrated, not just myself but in multiple centers throughout the country and the world, that you can do this safely with a similar or even lower complication rate than doing it in the OR. It really widens the breadth of who you can do this for.

Julie: Well, thank you very much for sharing your story and what you've developed with us. That sounds really interesting. And again, music to the ACO ears.

Ross: Absolutely. So, you know, just to summarize, I mean, I think when we talk about quality of care, I'm not changing outcomes at all. I'm decreasing cost with what I'm doing. I'm not saying that doing a carpal tunnel in the outpatient setting is a better carpal tunnel than doing it in the OR. There's no difference in how patients do. But I was reading some research the other day that the projection is that if every carpal tunnel, and there's half a million carpal tunnels done in the US each year, if all those carpal tunnels were done the way that I do them in an outpatient setting, that could save our health care system up to 100 million dollars a year. And that's one soft tissue surgery.

Julie: Right. Well, that's money we could spend somewhere else.

Ross: That's pretty impressive numbers right there.

Julie: Absolutely. Well, thank you again. And we look forward to hearing more about you and maybe this project and work that you're doing spreading.

Ross: Happy to help.

Mike: So thanks for listening to BACON this month. You can find all our episodes on your podcast app and at our Web page, MaineHealthACO.org/BACON. And if you have questions, comments and suggestions, we'd love to hear from you. Please email us at bacon@mainehealth.org. That's bacon@mainehealth.org.

Julie: Bacon is produced by the MaineHealth Accountable Care Organization with help from the MaineHealth Educational Services. Thanks for joining us. See you next month.

Mike: See you next month.