THE COMING CHANGES IN NEUROSURGICAL PRACTICE
The Continuum of Neurosurgical Care: Increasing
the Neurosurgeon’s Role and Responsibility
Edie E. Zusman, MD, MBA∗
Deborah L. Benzil, MD‡
∗
Division of Neurosurgery, NorthBay
Center for Neuroscience, Fairfield,
California; ‡ Department of Neurosurgery,
Columbia University, New York, New York
Correspondence:
Edie E. Zusman, MD, MBA,
Chief of Neurosurgery,
NorthBay Center for Neuroscience,
1860 Pennsylvania Avenue,
Fairfield, CA 94533.
E-mail: [email protected]
Received, September 2, 2016.
Accepted, January 28, 2017.
The Health Care Reform Act has fostered a shift toward capitation and shared risk among
providers to improve quality and reduce the escalating costs of healthcare. Like all
physicians, neurosurgeons are increasingly being incentivized to participate in efforts to
streamline care through the use of surgical pathways to reduce hospital length of stay and
prevent readmissions. These changes have expanded the role of the neurosurgeon along
the continuum of care for the neurosurgery patient. This paper predicts and advocates
for a further broadening of neurosurgery participation from programs that reward physicians for helping to prevent a high-risk patient’s need for surgery to management of
postacute rehabilitation. It also introduces the concept of risk reduction more generally
at the community level through collaborative interventions that improve health through
changes to the built environment, innovations in transportation, and improved access to
healthy food and recreation opportunities.
KEY WORDS: Continuum of Care, Health Care Reform, Patient Satisfaction, Reimbursement
Neurosurgery 80:S34–S41, 2017
DOI:10.1093/neuros/nyw151
www.neurosurgery-online.com
C 2017 by the
Copyright Congress of Neurological Surgeons
H
ealthcare reform measures have potentially profound effects on neurosurgery,
one of the most expensive areas in
medicine.1 The US Centers for Disease Control
and Prevention reports that there were approximately 1.2 million neurosurgical procedures
performed in 2010; lumbar laminectomies alone
exceeded $2 billion, and spinal fusions cost $12.8
billion nationwide in 2011.2
With healthcare reform has come a greater
emphasis on capitation of payments for care and
risk sharing among the stakeholders. That has
forced health systems, hospitals, and clinicians
to identify opportunities along the continuum
of care to lower costs and keep patients from
being readmitted to the hospital. These efforts
include standardized protocols, drug formularies,
and safety checklists, all of which may be most
efficiently coordinated and implemented when
physicians are financially or contractually aligned
with the health systems implementing them.
The shift toward quality and cost-effective
care, including prevention of hospital readmissions, is being driven by government healthcare
ABBREVIATIONS: LTAC, long-term acute care; EHR,
electronic health record; LOS, length of stay; ASC,
ambulatory surgery center; ACO, accountable care
organization
S34 | VOLUME 80 | NUMBER 4 | APRIL 2017 Supplement
reforms aimed at reducing healthcare inflation.
The Patient Protection and Affordable Care Act
is the most profound reform legislation passed
since 1965, when the Social Security Act was
amended to include Medicare and Medicaid.3
Healthcare reform measures were designed to
improve access and quality while also reducing
the cost of providing care.
In today’s healthcare environment, the role of
the neurosurgeon along the continuum of care
of patients must expand. Already within feefor-service payment structures, neurosurgeons
are assuming more responsibility for ensuring
quality prior to a procedure, as well as after
hospital discharge. As pressure mounts for
health systems and payers to further contain
costs and improve patient outcomes, neurosurgeons will no longer be permitted to simply
show up, operate, and move to the next case.
Their performance on aspects of care that
go beyond the operating room will increasingly determine financial success. Indeed, as
models of care evolve, neurosurgeons should
eventually be rewarded for helping prevent a
patient’s need for surgery altogether. This paper
defines the concept of continuum of care and
explores how neurosurgery is, can, and should
be integrated. The Continuum of Care for a
Neurosurgery Patient is illustrated in Figure.
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THE CONTINUUM OF NEUROSURGICAL CARE
FIGURE. The Continuum of care for a neurosurgery patient
THE ROLE OF THE NEUROSURGEON ALONG
THE CONTINUUM IN TRADITIONAL
FEE-FOR-SERVICE CARE
re-evaluation of the role of the neurosurgeon within the traditional fee-for-service model.
Historically, a neurosurgeon who works within a fee-for-service
system is not employed by the hospital or health system, but
operates within those facilities as a matter of privilege. Neurosurgeons collect fees from the patient and their insurer for
services delivered based on a predetermined rate. This model
may incentivize neurosurgeons to focus on quantity of procedures, especially those that are potentially more lucrative. In
this system, the neurosurgeon enters the continuum of care in
the middle, at the time a patient presents for an episode of
care. For elective cases, this may be only after a referral from a
primary care physician who may have exhausted less invasive or
seemingly less costly approaches to a patient’s condition such as
physical therapy and pain management. In this model, a patient’s
failure to adopt a healthier lifestyle—attaining and maintaining
a healthy weight, for example, is inconsequential, and the lack
of a patient’s involvement in preventive health measures may in
fact present opportunities for subsequent surgery. In the past few
years, the implementation of the Affordable Care Act has led to
WHAT IS CONTINUUM OF CARE?
NEUROSURGERY
Continuum of care is defined as “a concept involving a system
that guides and tracks patients over time through a comprehensive
array of health services spanning all levels and intensity of care.”4
It can include an array of healthcare services, including acute
care services, emergency and hospital services, physician practices,
rehabilitation centers, skilled nursing, long-term and palliative
care, and hospice. The continuum of care can also include
public health and wellness services that aim to prevent disease.
Capitated healthcare systems and all other healthcare stakeholders
increasingly recognize that healthcare expenditures are lowest for
healthy people and that healthy habits begin at home and in the
community, long before people become patients. As a result, the
health sector is increasingly partnering with nonprofit organizations on interventions that engage urban planners, designers,
the public sector, transportation and food system managers, and
public health, to improve community health.5
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ZUSMAN AND BENZIL
Continuum of Care: Neurosurgeons Begin Involvement
In some fee-for-service systems, neurosurgeons are called upon
to help determine neurosurgery referral protocols, but generally
have no direct incentives to participate in other aspects of the
patient’s care because this model does not reward the neurosurgeon to do so. For example, neurosurgeons are rarely involved
in decisions around utilization of staff and facilities. Physician
engagement in these types of integrated pathways has increased,
however, and Medical Directorship contracts, which provide
payment to neurosurgeons for administrative work and program
development, are an incentive to participate. These kinds of
financial alignments have helped bring neurosurgery representation “to the table” to work jointly with hospital leadership
to lower costs of care, including decreasing costs for implants
and hardware, but incorporation of the surgeon may well be
downstream from the initial presentation for a given episode
of intervention. Health systems and third-party payers have
heightened scrutiny of individual surgeons’ costs to provide care
with collection of data on cost and time per case, as well as length
of stay (LOS) during a specific episode of care. Aligned neurosurgeons are increasingly involved in discharge planning and
confirming arrangements for patient follow-up once the patient
is discharged. There remains, however, little connectivity between
neurosurgeons and home health providers, acute rehabilitation
facilities, long-term acute care (LTAC), and skilled nursing facilities.
At the same time, neurosurgeons are increasingly being held
more accountable for patient care at more points along the
continuum. Healthcare reform measures demand that neurosurgeons take a larger role in presurgery planning and education,
care documentation using the electronic health record (EHR),
and a host of other measures to reduce hospital LOS and
the risk of readmission and to increase patient satisfaction
scores.
Neurosurgeons are taking more responsibility for providing
patients relevant information to streamline the episode of care.
For elective procedures, the neurosurgeon ensures the patient and
their care providers know what to expect and how to prepare for
surgery. Through a preoperative class, educational video, and/or
brochure, or through conversations with the surgeon and staff,
neurosurgeons set postoperative expectations and engage patients
in their own care.6 At David Geffen School of Medicine at
UCLA, for example, patients preparing for microvascular decompression surgery are provided the expected goals of hydration
and nutrition, mobilization, elimination, and pain and nausea
control to demystify the postoperative setting and establish
shared expectations.6 The neurosurgeon, nurse practitioner, or
physician assistant colleagues are frequently providing postoperative instructions during the patient’s preoperative visit and
writing postoperative medication prescriptions. Filled medication
prescriptions can be double-checked for accuracy upon hospital
discharge. Postoperative office visits also can be scheduled ahead
of surgery.
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This approach has recognized success in improving efficiency,
managing patient expectations, and decreasing LOS. When
patients know what to expect prior to neurosurgery, there are
fewer calls back and forth from patient to physician. Patient satisfaction improves when patients follow an expected postoperative
program, and when patients are satisfied, they are more likely
to rate their care well on patient satisfaction surveys. Starting in
fiscal year 2015, the federal government based 30 percent of a
hospital’s performance score on patient satisfaction.7 Low scores
on patient satisfaction can negatively affect a hospital’s Medicare
reimbursement rate.
Patient satisfaction survey data is also made public, providing
additional incentives to hospitals and clinicians to perform better.
Among the survey’s measurements are how well the patient was
informed about pain management and use of other medicines
and whether they were given clear discharge instructions. By
initiating discharge education preop, the neurosurgeon has the
ability to assure this measured part of care has been performed as
they direct. These carrot-and-stick approaches are slowly pushing
neurosurgeons and health systems to align with the continuum of
care of our patients.
New Challenges in Continuum of Care: Hospitalists and
Emergency Care
For trauma and hospital-based neurosurgeons, there may be
even less engagement in continuum of care of the patient.
Patients may have no history with the hospital to which they are
being taken or with the neurosurgeon on call who will perform
their emergency intervention. With the success of the American
College of Surgeons Trauma System, patients are triaged not
to the closest hospital but the hospital with the appropriate
level of neurosurgical care, which may be a high-level trauma
center several hours away with an available neurosurgeon.8 This
approach, which employs best practices, surgical protocols, and
surgical checklists, improves patient outcomes, allowing hospitals
to provide the appropriate level of care and staffing for patients of
a given acuity.
This shift, however, has resulted in a change to the continuum
of care for emergency neurosurgery patients. Unlike in the past,
when the attending neurosurgeon at the closest hospital would
continue to follow that patient through the course of the hospital
stay and through follow-up clinic appointments, patients with
neurosurgical emergencies now are typically returned to their
local physicians and facilities for follow-up care. The patient may
never again see the neurosurgeon who operated on them, thereby
placing new challenges on the postacute continuum of care.
In this emergency care model, the neurosurgeon has served as a
consultant, and the patient is not a single physician’s responsibility
but that of the neurosurgical, intensive care, or trauma service.
During hospital stays, trauma surgeons, critical care teams, and
hospitalists oversee patient care, a practice that has been touted
for reducing medical errors but may further fragment care. The
change to hospital-based teams of doctors, including the critical
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THE CONTINUUM OF NEUROSURGICAL CARE
care physician, trauma surgeon, and neurosurgeon, has created
an unintended consequence: the physicians who took care of the
patient during a life-or-death situation likely will not see the
patient on an outpatient basis or even follow the patient daily
through their lengthy hospital stay. In this scenario, the patient’s
primary care physician, the doctor who knows the patient and
his/her family best, may be many miles away, or, if they are in the
same community, may have given up their hospital privileges with
the dramatic shift to inpatient hospitalist teams.
Aiding Continuum of Care: The Illusive Potential of EHR
Many anticipated that widespread implementation of EHR
would dramatically facilitate patient care, including continuum
of care efforts. For a variety of reasons, however, this goal has
remained unrealized despite the high costs of these systems. To
try and foster these efforts, the federal government has provided
financial incentives to hospitals and physicians who have proven
to be “meaningful users” of EHR systems, which capture and
share patient histories and treatments and track clinical progress
over time. The technology aims to improve care coordination
among providers, enhance quality, reduce healthcare disparities,
and engage patients and their families in their healthcare. In 2015,
hospitals and other providers who have not adopted EHR systems
became subject to penalties.
Implementation of the EHR in hospitals further engages the
neurosurgeon in the continuum of care for their patient. The
neurosurgeon is responsible for entering preoperative information
into the system, including preoperative orders and an updated
history and physical exam within 24 h of surgery. This has created
a new preoperative workflow for neurosurgeons and their staff.9
But while implementation of the EHR promised easy access to
patient information among and between health systems and along
the continuum of care, that functionality has not been fully
realized. Gaps remain, which impede progress to streamline the
role of neurosurgeons in a patient’s care before, during, and after
surgery.
Continuum of Care: Neurosurgical Readmissions
Hospitals are under even greater pressure to avoid “hospitalacquired conditions,” defined by the Centers for Medicare and
Medicaid Services as preventable adverse events because they do
not qualify for reimbursement.10 Thirty-day readmission rates are
increasingly being used as a metric for both quality and value
in healthcare. Neurosurgical readmissions are among the most
costly, at nearly $30 000 per readmission, and unlike other types
of surgery, have not yet decreased.11 The scrutiny has led to
increasing research within the specialty to better understand the
readmission rates and begin to address them.
A recent study found that many readmissions in neurosurgery
are preventable and occur at predictable time intervals.11 An
analysis of adult admissions for neurosurgical or neuroendovascular procedures over nearly 4 years in New York State found that
readmission rates varied by diagnosis and type of intervention:
spine had the lowest rate (6.46%), followed by cranial, noncran-
NEUROSURGERY
iotomy (8.64%), neuroendovascular (9.26%) with highest rates
in cranial, craniotomy (15.88%).11 The reasons for readmission
ranged from surgical site infections to respiratory failure, seizures,
strokes, and device malfunctions. This suggests the potential
for prediction models to allow targeted interventions to lower
readmission rates among high-risk patients to reduce costs and
patient morbidity.
Continuum of Care: LOS
In addition to meaningful use of EHR and analysis of
readmission and complication rate reductions, healthcare payers
also are judging clinicians and hospitals on patient hospital LOS.
Because shorter hospital stays can result in more readmissions
due to unresolved or unanticipated postoperative complications,
meeting both patient-quality and cost-control goals can create
conflicts. Within neurosurgery, same-day surgery is replacing an
overnight stay in the hospital for a number of procedures. Patients
undergoing more complex surgeries have discharges after even
shorter LOS. Studies demonstrate that these approaches can be
both good for patients and for lowering costs of care. Annual cost
savings of $140 million have been reported for specific outpatient spine surgeries.12 A retrospective study of 1000 patients who
had anterior cervical discectomy and fusion either in the hospital
or in an outpatient ambulatory surgery center (ASC) demonstrated that complication rates were low and easily diagnosed and
managed without compromising surgical safety within the ASC.13
To succeed, such changes require patients and staff have
additional education and training to successfully move from
inpatient to outpatient neurosurgical care. To avoid the initial
negative feedback from patients regarding the earlier discharges,
neurosurgeons and their hospitals are preparing patients better
about expectations upon discharge, as well as offering classes and
other tools to help them in their recovery at home. Earlier hospital
discharges also have led to a growing home healthcare industry,
which enlists nurses and other providers such as occupational
and physical therapists to help patients rehabilitate at home. A
thorough cost analysis on a systems basis has yet to be completed.
CONTINUUM OF CARE WITH EVOLVING RISK
MODELS: THE NEUROSURGEON’S ROLE
Accountable Care Organizations: Prototype of Current
Risk Models
As pressures under healthcare reform grow, so have opportunities for new value-based models of care delivery and physician
reimbursement designed to change the incentives for both
providers and patients, based on what has been termed “value
of care.” These value-based care arrangements are implemented
in a variety of ways by and among physician groups, hospitals
and health systems. Certain systems’ implementation of valuebased care alters the rules that govern provider reimbursement so
that income depends on quality and safety measures, provision
of recommended care, and avoidance of wasteful care, beyond
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ZUSMAN AND BENZIL
provision of a service. The concept focuses on measuring value
and reforming payment methods for services to reflect that
value.14 For most of these systems, a multifaceted physician
alignment strategy is a necessary ingredient for success.15
Among the growing value-based models are accountable care
organizations (ACOs), authorized by the Affordable Care Act, in
which groups of physicians and other partners such as hospitals
take responsibility for the cost and quality of care for a set of
Medicare patients and share in the savings if total costs are reduced
below the benchmarked, expected costs.16 ACOs are designed to
motivate healthcare providers to decrease the preventable episodes
of care for a given patient through increased care coordination.
ACOs employ a range of payment models, which may include
capitation or fee-for-service in how they remunerate neurosurgeons, but unlike traditional fee-for-service systems, in which
each episode of care is reimbursed by private or government
payers, each episode of care in an ACO model is viewed as a cost
to the system.
How might surgical specialties fit into this emerging healthcare
model? An analysis of 59 ACOs found that while surgeons
account for significant care for an ACO’s patients, they have
largely been uninvolved in ACO efforts, which have mostly
focused on coordinating care for patients with chronic conditions such as congestive heart failure and diabetes, and reducing
unnecessary hospital readmission and emergency department
visits.16 This is likely an appropriate focus when global analysis
of preventable cost is undertaken.
No doubt, over time, ACOs will integrate surgeons and other
specialists into their organizational plans and hope to focus on
coordination of care to further avoid wasted resources. Surveyed
ACOs indicated that for this they prefer surgeons who provide
high-quality care at low cost and are able to communicate well
with primary care colleagues.16
Neurosurgery: Value of Care Efforts
One way in which neurosurgeons are engaged at an earlier
point in the continuum of care is development of a triage system
to ensure patients receive the optimal level of care. Without
well-established guidelines and other screening protocols, patients
presenting with common and costly conditions such as back and
neck pain, may receive too many and inappropriate interventions. This will include both under- and overreferral for services
such as costly imaging, physical therapy, pain management,
and surgical evaluations. Working with other team members,
including midlevel practitioners, pain management specialists and
physiatrists, for example, neurosurgeons can guide the decisionmaking process for care for patients who may or may not need
surgery.
The role of neurosurgery in the ACO and similar models of
healthcare delivery presents obvious challenges, since neurosurgical care is among the most costly of all specialties. But organized
neurosurgery already is actively working to address the everincreasing costs of neurosurgical care. The specialty has embraced
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the Choosing Wisely campaign, launched by a consortium of
medical societies and Consumer Reports, targeting 5 clinical tests
and/or procedures to reduce wasteful use. It has responded to
demands for value-based care by supplying data to better understand quality and cost.17 Additionally, hospitals are increasingly
calling on neurosurgeons to help in the selection of equipment to
reduce expenses and support other cost-saving measures. Other
important initiatives for neurosurgery include data collection
platforms such as NeuroPoint Alliance for national registry participation by all neurological surgeons in the US and the National
Neurosurgery Quality and Outcomes Database. Both serve as the
principal practice sciences infrastructure for each area of neurosurgical subspecialty practice.18
In ACOs and in other risk models of care, neurosurgeons are
working directly with hospital administrations and other stakeholders to devise clinical pathways for neurosurgical care that is
driven by best practices. Establishment of neurosurgical pathways
can be easier in an ACO setting than in a traditional fee-for-service
system because physicians in ACOs have to be more accountable
for quality of care they deliver and are incentivized to adhere to
best practices. By the same token, they have less freedom to work
independently from the health system or hospital, which has more
oversight in how care is delivered. In contrast, in traditional feefor-service systems, it is harder to roll out cost-saving best practices
because independent physicians generally have the choice of their
practice pattern; buy-in is more voluntary.
Continuum of Care: UCLA Pioneering Efforts
The neurosurgery program at University of California, Los
Angeles Geffen School of Medicine, a system in which the physicians are employed by the health system, has documented its
approach to improve the value of neurosurgical care through
multifaceted and multidisciplinary efforts. These include performance processes prior to, during, and after surgery. Careful
monitoring of the key processes facilitated improvement of the
value of care delivered to patients.6 For example, an analysis
of microvascular decompression surgeries before and after the
program was implemented found that the processes led to “an
improvement of global outcome with maintenance of a zero
mortality rate and high degree of symptom resolution, reduction
in the average preincision preparation time, decrease in the
average total operating room time, decrease in the mean and
median overall LOS, decrease in the mean LOS on the floor, and
reduction of complications and the number of readmissions.”6
Continuum of Care: Other Initiatives
Some countries’ healthcare systems already utilize broadly
accepted neurosurgical pathways that specify evidence-based
practices for all neurosurgical procedures. In England, for
example, 25 neurosurgical units adhere to a single clinical
pathway developed with aims to reduce the morbidity and
mortality of neurosurgical conditions, minimize pain and
disability, optimize functional recovery, and improve the quality
of life of neurosurgical patients. To achieve the established aims,
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THE CONTINUUM OF NEUROSURGICAL CARE
the pathway states that “neurosurgical patients should receive the
highest levels of patient-centered, multidisciplinary care in the
most appropriate environment.”19
A Canadian study reported that a coordinated, multidisciplinary pathway with a stratified approach to low-back pain
assessment and care provided may allow surgeons to restrict their
practices to patients who are more likely to benefit from their
services, thereby reducing wait times and potentially reducing
costs.20
Clinical pathways are not always embraced by physicians, who
may see them as a cookie-cutter approach to patient care that
leaves little room for practice of the art of medicine.21 Even with
adherence to a clinical pathway, the clinician should tailor care
management to the individual patient or risk ordering unnecessary tests or treatments.
Continuum of Care: After Hospitalization
Still largely overlooked in continuum of care, efforts are
posthospital interventions and patient management. Few valuebased systems integrate postacute care, thus limiting incentives to
ensure patients are placed in an appropriate setting after surgery
to optimize their recovery and reduce 30-day readmission rates.
Such settings might be rehabilitation centers, skilled nursing facilities, LTACs, or home care.
Several problems in coordinating postacute care for patients
have been identified. Among them are poor information sharing,
difficult and unsatisfactory care transitions, and misaligned
financial incentives.22
However, ACOs that have a formal relationship with a
postacute provider are more likely to have advanced transition
management, end-of-life planning, readmission prevention, and
care management capabilities.22
Integration of postacute services in ACOs and other systems is
not well established, but some health systems view integration as
an opportunity. Ascension Health, the nation’s largest nonprofit
health system, with 70 general acute care hospitals in 20 states
and the District of Columbia, has taken on postacute care for
its patients through a reorganization aimed at reducing 30-day
hospital readmissions.23 Ascension has 34 senior-care facilities
across the country. The nonprofit system reported that after just
1 year, the nonprofit saved $42 million on the provision of acute
care as a result of decreased patient LOS in acute care facilities—
faster throughput through the costly acute phase of the care
continuum.
THE NEXT ITERATION? NEUROSURGEONS AS
CARE ADVOCATES THROUGHOUT THE
CONTINUUM OF CARE
In this era, when health systems, physician groups, and
hospitals experiment with various integrated healthcare delivery
models with physician alignment and reimbursement schemes
deliver value-based care, neurosurgeons not only have an oppor-
NEUROSURGERY
tunity to make an impact but also have an imperative. Neurosurgeons are experts in surgical interventions for complex spine and
brain conditions, but their expertise could have greater impact
if it is also used to promote prevention of serious neurological
events. To assure the highest quality of neurosurgical triage and
decision making, neurosurgeons do have a role in making sure
that patients who need surgery or a higher level of care are
properly evaluated for tumor, myelopathy, or spinal instability,
but also deciding when surgery is not appropriate. In those
instances, neurosurgeons may be uniquely effective in motivating
patients to take charge of their health through weight loss, core
strengthening, smoking cessation, or other noninvasive steps.
Later in the continuum of spine care, neurosurgeons are key to
supporting effective postoperative care and rehabilitations so that
more patients may go on to live healthy, productive lives without
the need for hospital readmission or future spine surgery procedures.
Once again, Ascension Health, has made significant strides
to initiate a comprehensive and integrated prevention program
that maximizes reward and minimizes risk.15 They are doing
it through integration of services. They understand that
involvement of physicians—including specialists—is critical to its
success, and their leaders view provider efforts to prevent illness
as key to fulfilling their mission.15
“In an ideal world—hopefully within ten years—groups of
clinically integrated healthcare providers will be evaluated and
incentivized on the basis of how healthy they keep their patients,”
said Peter M. Leibold, Ascension Health’s chief advocacy officer.15
David B. Pryor, MD, executive vice president and chief clinical
officer of the company, echoed his colleague: “I see a model
in which patients are supported beyond the service provided to
reduce future interventions and complications. Ideally, we would
go even further, by supporting care for individuals who do not
yet need interventions, thus preventing or delaying the onset of
chronic diseases and managing overall healthcare and cost of care
beyond a single-year horizon.”15
With the right incentives in place, new healthcare models can
address increasing costs of care and high hospital readmission
rates associated with chronic illness. In neurosurgery, for example,
opportunities exist to develop and manage programs that help
patients reduce their risk for stroke and the need for spine surgery
through weight loss, nutrition, and exercise/physical activity.
Integration of disease prevention programs could also improve
quality of care and patient satisfaction measures, which result in
better Medicare reimbursement rates.
Attracting and engaging physicians and specialists to take
part in the continuum of care require a variety of health
system–physician-contracting options. The various remuneration models for neurosurgeons will play a role in aligning
physician behaviors and interest around a patient’s continuum
of care. Successful hybrid financial relationships are expanding
for independent practice physicians who take on shared goals
around program development, quality and outcomes, as well as
volume-based independent goals based on productivity. These
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ZUSMAN AND BENZIL
arrangements provide incentives to neurosurgeons who provide
neurosurgical services but also take on medical directorships,
trauma and vascular calls, and even healthy spine clinic. In
this scenario, program incentives are aligned up front and
discussed.
NorthBay Healthcare in Northern California is embarking
on construction of a 100 000-square-foot wellness clinic which
will host the NorthBay Center for Neuroscience Healthy Spine
Program, paid for through a mix of fee-for-service and a
NorthBay-owned health plan. Patients who use the facility
services may be in fee-for-service or capitated plans. NorthBay
providers will sign professional service agreements that define
their responsibilities and payment structures for each, physicians
maintaining autonomy in decision making around neurosurgical
and clinical resources and how individual patients are cared for.
The goal is to incentivize neurosurgeons and the multidisciplinary
care team to do what is right for the patient, even if that means
keeping the patient out of the operating room.
This approach can also work to prevent readmissions. Even
if neurosurgeons are hesitant to get involved in more aspects
of the continuum of care, pressure to lower readmission rates
will require it. Neurosurgeons will have to buy in to the idea
that they should ensure that nutritional support, weight loss or
weight maintenance, core strengthening, and other preventive
measures are being addressed for patients at risk of subsequent
recurrence or gradual progression of underlying conditions after a
first neurosurgical episode of care. Partnering with postacute care
programs, outpatient rehabilitation teams, and patients’ primary
care physicians can facilitate that involvement and, at the same
time, improve the health and wellbeing of patients.
Continuum of Care: Healthy Communities
Health maintenance along the continuum of care begins in
the community, and healthcare providers can and should be part
of that effort to achieve true cost savings. Just as we build our
cities, towns, and communities, they build us as well, physically,
socially, mentally, and even spiritually. These social determinants
of health include how we design transportation systems, housing
and parks, as well a community’s access to healthy food, public
health, healthcare, and safety services.
Lack of sidewalks, bike paths, and recreational areas in some
communities discourages physical activity and contributes to
chronic disease,24 which can lead to the need for costly healthcare,
including neurosurgery.
As evidence mounts on the links between the built
environment and population health, many cities are joining
forces with nonprofit groups and healthcare providers to address
these disparities. In Sacramento, California, for example,
a collaborative team of professionals from various sectors,
including medicine, worked together to develop Design 4 Active
Sacramento, which established inclusion of health elements in
the county general plan, zoning code, and design guidelines.
Design 4 Active Sacramento outlined the rationale for design
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strategies that promote health and sustainability. These include
building mixed-use, compact communities, well-connected
roadway networks, site and street design that considers how
people perceive and interact with their environment, including
sidewalks, bike lanes, and other amenities.25
For healthcare systems to achieve true reform that both
improves quality of care and reduces costs, engagement from every
sector of society including patients will be essential. Driven both
by incentive and imperative, neurosurgeons like all healthcare
providers must play a role in the process to improve the health
of our communities. Increased neurosurgeon engagement at more
points along the continuum of care will have a profound influence
on how that is achieved.
Disclosures
Both Dr. Benzil and Dr. Zusman are founding partners in Benzil Zusman,
LLC, a consulting company that specializes in neuroscience and healthcare negotiations, strategy, and program development. Many of the concepts presented relate
to the work they do and have done for clients.
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THE CONTINUUM OF NEUROSURGICAL CARE
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COMMENT
T
he conceptual basis of payment reform based on financial risk shift
from insurers to healthcare providers and systems cannot be understood without a grasp of the idea of the “continuum of care”. The cost
risk for an insurer under traditional fee-for-service payment includes
all services provided to a patient, or more inclusively, a population of
patients (or clients) covered by the insurers policies. When the cost for
the total period of care over a defined period of time (“capitation”), or
NEUROSURGERY
even the total episode to care (“bundled care”), is shifted to the provider of
care, control of cost becomes a care provider’s responsibility and financial
liability, including costs for which the provider previously had no interest
or leverage. Those costs include primary and preventive services, acute
care inpatient or outpatient services, post-hospitalization rehabilitation
care – including both institutional and home care, and prevention of rehospitalization for foreseeable complications.
The continuum of care under risk-based reimbursement becomes a
concern of the entire system, as financial losses or penalties affect all
participants in the enterprise, whether employed or contracted, since
the profit to be made or money to distribute directly or indirectly
affects all in the system. Bonuses, salaries, technical equipment purchases,
facility amenities and expansions, services offered, and administrative and
clinical personnel additions all depend on the profitability of the entire
system. When all share in the consequences of profitability, everyone is a
piece of the continent; no one is an island.
In “The Continuum of Neurosurgical Care: Increasing the Neurosurgeon’s Role and Responsibility”, Edie Zusman and Deborah Benzil
describe this new nexus of organizational responsibilities and how they
apply to the neurosurgeon participating in organized systems of care
engaged in risk contracting. The point of the discussion is how a neurosurgeon, with a role traditionally limited to narrow surgical treatment
protocols, can fit into the wider scheme of total patient care management,
using the neurosurgeon’s unique knowledge, training, and experience to
design and oversee the system of care. Mentioned are referral protocols,
program directorships, patient education and expectation management,
optimal emergency referral network design, tactics to reduce lengths
of stay and hospital readmissions, establishing cost-effective diagnostic
and treatment guidelines, and tailoring care management to individual
patients.
The authors correctly believe that the neurosurgeon must find and
define a new role as “care advocates throughout the continuum of care”.
How this will be done is a work in progress, and this essay is a guide to
organizing the concept and plan.
James R. Bean
Lexington, Kentucky
VOLUME 80 | NUMBER 4 | APRIL 2017 Supplement | S41