Improving Value in Surgery

Abstract

A radical and essential transformation in health care delivery is underway. Fee-for-service (FFS) has long held sway as the primary payment model in the United States, rewarding providers and hospitals for volume but not for quality or costs of services provided, and is largely responsible for the staggering growth of health care spending. The Affordable Care Act, enacted in 2010, is shifting incentives away from volume and toward a Triple Aim of better care, improved health, and reduced spending. Likewise, patients are becoming more sophisticated consumers of their health care, and payers are aggressively seeking new payment models that incentivize health systems to improve outcomes, enhance patient experience, and lower costs. Whereas much of this effort has focused on primary care providers (eg, accountable care organizations and patient-centered medical homes), surgeons have a critical role in improving the value of health care in the United States. Costs of surgical procedures far outweigh primary care services, accounting for nearly half of all Medicare spending.1 In addition, surgeons often lead the management of patients with complex, potentially costly medical problems. Every surgeon can readily identify defects in value, which are occurrences in the management of their patients who compromise quality and patient experience and increase costs. Examples of defects in value are abundant across health care, accounting for at least $1.3 trillion in wasted spending.2 Opportunities for improvement in surgery are emerging related to avoidable complications, readmissions, overtreatment, no-value-added technology, and lack of specialist care.3 DEFECTS IN VALUE IN RECTAL CANCER CARE AND OPPORTUNITIES FOR REVERSAL Perhaps no other area within the field of surgery has as much opportunity to eliminate defects and, thereby, improve the value of care as rectal cancer treatment. Rectal cancer is a complex disease. It is best managed by a multidisciplinary team (MDT) of expert providers using an array of treatment modalities aimed at maximizing oncologic benefit while minimizing adverse treatment effects. Innovations in the past several decades in neoadjuvant therapy, surgery, and imaging have undoubtedly improved overall patient outcomes. Nonetheless, they have also created treatment algorithms with convoluted options that have differences in benefit, harm, patient inconvenience, and cost. Providers caring for rectal cancer patients will be increasingly asked to not only create a treatment plan focused on cancer outcomes, but 1 that incorporates the value equation variables−patient goals/experience and treatment costs. Figure 1 illustrates 8 defect domains in rectal cancer treatment, creating no-value care (no clinical benefit and may harm the patient) and low-value care (higher cost with little-to-no clinical benefit or decreases in both cost and quality-adjusted life years). By no means all-inclusive, these examples are meant to stimulate rectal cancer providers to critically assess the cost–benefit ratio of each step of treatment algorithms with the goal of providing the highest value care possible for each patient. Below we discuss several of these defects in rectal cancer care and the potential cost savings if they were eliminated (Table 14–12).FIGURE 1: The figure shows the domains of defects in rectal cancer treatment, situated on a cost-effectiveness plane relative to high-value, low-value, or no-value care. Value is considered on a sliding scale based on clinical benefit, cost, and quality-adjusted life years (QALY), in which the greater the clinical benefit and QALY for the patient and the lower the cost, the higher the value. TABLE 1 - Value Defects in Rectal Surgery and Potential US Health Care Cost Impact Rectal Cancer Value Defect Domain(s) US Societal Cost Overtreatment with neoadjuvant therapy Inappropriate care $166,078,880* 4,5 Difficulty supporting shared decision-making Loop ileostomy Inappropriate care $18,001,17