‘Lead­ers in the in­dus­try have an op­por­tu­nity to rise to the oc­ca­sion and make a dif­fer­ence’

Modern Healthcare - - Q & A -

“Price is what you pay; value is what you get. And as the health­care in­dus­try evolves, dis­tin­guish­ing the dif­fer­ence is re­ally, re­ally hard for every­one.”

For more than 150 years, the mis­sion of the Hospi­tal for Spe­cial Surgery in New York City has been to pro­vide high-qual­ity, ef­fi­cient care for or­tho­pe­dic and rheuma­tol­ogy pa­tients. The hospi­tal per­forms roughly 29,000 sur­gi­cal pro­ce­dures a year, in­clud­ing 365 joint re­place­ment op­er­a­tions and 294 non-cer­vi­cal spine fu­sions. At the helm of the or­ga­ni­za­tion since 2006 is Lou Shapiro, a vet­eran health­care ex­ec­u­tive who pre­vi­ously served as chief op­er­at­ing of­fi­cer of Geisinger Health Sys­tem in Penn­syl­va­nia. Shapiro stopped by Mod­ern Health­care’s Chicago of­fices to speak with safety and qual­ity re­porter Maria Castel­lucci about HSS’ unique care-de­liv­ery ap­proach, its ef­forts to ex­pand and how to achieve value in health­care. The fol­low­ing is an edited tran­script.

MH: What makes HSS’ ap­proach unique in the or­tho­pe­dic and rheuma­tol­ogy land­scape?

Lou Shapiro: There’s a con­cept called Fo­cused Fac­to­ries where or­ga­ni­za­tions, whether they’re in man­u­fac­tur­ing or health­care, what­ever they do, they have a great deal of vol­ume in one area. All of their sup­port sys­tems are or­ga­nized around it and they pro­duce a bet­ter re­sult than the same kind of or­ga­ni­za­tion that’s not fo­cused.

HSS has a long his­tory of hav­ing that fo­cus and a com­mit­ment to ex­cel­lence that’s in the DNA of the or­ga­ni­za­tion. Em­ploy­ees, re­gard­less of what role they play, view it as a priv­i­lege to be part of HSS and un­der­stand the com­mit­ment that’s re­quired to make HSS able to ful­fill its pur­pose; if you’re not ful­fill­ing that pur­pose, then you have no pur­pose. It’s also about tal­ent. Re­gard­less of the evo­lu­tion of tech­nol­ogy—rang­ing from ro­bot­ics to ar­ti­fi­cial in­tel­li­gence—in health­care, for the fore­see­able fu­ture, tech­nol­ogy is an en­abler, but it’s still peo­ple tak­ing care of peo­ple. And the abil­ity to re­cruit and re­tain peo­ple who are the best at what they do in all fields is a driver of suc­cess of any or­ga­ni­za­tion.

A de­riv­a­tive of the Fo­cused Fac­tory and the cul­ture is that ev­ery­thing you do is or­ga­nized around a pa­tient type. You put all that to­gether, not by ac­ci­dent but by de­sign, and that’s when the real def­i­ni­tion of value comes to life. Value is a great word, but un­der­stand­ing what it means is even more im­por­tant. It’s used ex­ces­sively to­day, but there’s a clear for­mula for it: qual­ity plus ser­vice over cost is sort of the base­line equa­tion. Price is what you pay; value is what you get. And as the health­care in­dus­try evolves, dis­tin­guish­ing the dif­fer­ence is re­ally, re­ally hard for every­one.

MH: What do you think is needed to make that eas­ier?

Shapiro: In gen­eral, it’s hav­ing a com­mon lan­guage and a com­mon sys­tem of mea­sure­ment. The way some sys­tems are mea­sured to­day, you could have two pa­tients who had spine surgery and you could be mea­sur­ing what it cost and what were the out­comes, and one may be bet­ter than the other. But, what if the pa­tient didn’t need surgery, that they should have been treated with a non­op­er­a­tive ap­proach?

The sys­tems aren’t ma­ture enough to mea­sure that. Only some in­sti­tu­tions at­tract pa­tients for sec­ond opin­ions. So those or­ga­ni­za­tions have a unique view into the in­dus­try, be­cause they can see what’s hap­pen­ing else­where. We had two tools to mea­sure out­comes for hip and knee re­place­ments. But be­cause they’re long and com­pli­cated, pa­tients weren’t fill­ing them out. Our out­comes sci­en­tists stud­ied that and de­vel­oped a way of track­ing and mea­sur­ing out­comes. That was pro­mul­gated be­cause it was stud­ied, it was pub­lished, and now that’s what every­one uses.

I think that’s what has to hap­pen, sort of from the bot­tom up. The govern­ment’s not go­ing to solve our prob­lems for us. The large groups that rep­re­sent every­one are prob­a­bly not go­ing to solve

our prob­lems for us, not in the way that we need to. But lead­ers in the in­dus­try have an op­por­tu­nity to rise to the oc­ca­sion and make a dif­fer­ence.

MH: What are your thoughts on bun­dled pay­ments for joint re­place­ments? Is that mov­ing the nee­dle to­ward value?

Shapiro: Health­care, to a cer­tain ex­tent, is still a cot­tage in­dus­try, and one of the con­se­quences of that, as things be­come more com­pli­cated, is care has be­come frag­mented. If you take any­thing that’s frag­mented, it’s prob­a­bly go­ing to be more ex­pen­sive and it’s prob­a­bly not go­ing to be as good. So the con­cept of bun­dles is very ba­sic. In­stead of pay­ing 10 peo­ple to take care of one pa­tient, I’m go­ing to pay one per­son and I’m go­ing to pay them less, and that’s go­ing to force them to not be frag­mented. The prob­lem with it is it’s just not that easy.

At HSS, we par­tic­i­pate in bun­dles pro­grams. But we do that be­cause it’s a trend in the in­dus­try, and that’s what the buyer wants. We were never frag­mented, so we’ve been de­liv­er­ing the value of a bun­dle re­gard­less of how we’ve been paid. This no­tion of vol­ume to value, there’s some truth to it, but it’s also a lit­tle in­sult­ing to those that have al­ways been de­liv­er­ing value.

I re­mem­ber sit­ting around the ta­ble with Dr. Don Ber­wick (for­mer CMS ad­min­is­tra­tor and head of the In­sti­tute for Health­care Im­prove­ment) 20 years ago, talking about ex­actly the same thing with the same pas­sion that we’re talking about now. How do we make things bet­ter?

So bun­dles are not rev­o­lu­tion­ary. You can ar­gue about how it’s be­ing done and whether it’s suc­cess­ful or not, but you can’t re­ally ar­gue with the prin­ci­ples of it, right? Ac­cess, cost, qual­ity. It’s im­pos­si­ble to ar­gue with that. How you do that is a to­tally dif­fer­ent story.

MH: Can you talk about this role of the chief value med­i­cal of­fi­cer that you cre­ated and why you thought it was im­por­tant?

Shapiro: Be­fore the word “value” was promi­nently used in the lit­er­a­ture, we said to our­selves, “We need to do a bet­ter job of ar­tic­u­lat­ing our value propo­si­tion to our key stake­hold­ers,” who are our pa­tients, any­one who’s in­volved in re­ceiv­ing care or pay­ing for care. And we specif­i­cally said, “Our pa­tients,” or con­sumers and pa­tients, de­pend­ing on where they are, and “em­ploy­ers, in­sur­ance com­pa­nies.” It’s harder to com­mu­ni­cate with the govern­ment, so we didn’t re­ally in­clude that, but “Con­sumers, em­ploy­ers, pay­ers.”

We not only need to do a bet­ter job of be­ing able to ar­tic­u­late our value propo­si­tion, we need to fig­ure out ways to im­prove it, even though we led the in­dus­try. We worked at it and worked at it and we got bet­ter at com­mu­ni­cat­ing it.

We con­tin­ued to make im­prove­ments just like we al­ways have, and then we de­cided that we needed to bring in a physi­cian leader who un­der­stands qual­ity and value-just like we have peo­ple who are sort of the best and bright­est at tak­ing care of peo­ple whose back hurts or pa­tients who have os­teoarthri­tis, or pa­tients who have lu­pus, or what­ever.

We iden­ti­fied a per­son who was a qual­ity leader at a ma­jor health in­sur­ance com­pany, on the fac­ulty of a ma­jor uni­ver­sity and re­search com­pany, and hap­pened to have her base spe­cialty in an HSS-re­lated field, rheuma­tol­ogy. She knew a lot about back pain.

She knew a lot about os­teoarthri­tis, and she knew a lot about qual­ity and value. So we said that we were go­ing to cre­ate a lead­er­ship role for her to drive the jour­ney to­ward im­prov­ing our value propo­si­tion. And she is our chief value med­i­cal of­fi­cer and she leads our Value Man­age­ment Of­fice, which is a group of data sci­en­tists and bio­statis­ti­cians and qual­ity pro­fes­sion­als who study these things and help us fig­ure out what we need to do to com­mu­ni­cate and what we need to do to im­prove.

That’s all un­der the ban­ner of the Cen­ter for the Ad­vance­ment of Value of Mus­cu­loskele­tal Health, which is our com­mit­ment to play­ing a lead­er­ship role to pro­mul­gate this in aca­demic and in­no­va­tive ways in­side HSS and across the in­dus­try.

MH: How do your global ef­forts ad­vance that com­mit­ment?

Shapiro: We’re try­ing to do two things. One is through an or­ga­ni­za­tional model that we’ve cre­ated called HSS Global Ven­tures, which is in­tended to repli­cate our busi­ness model in other ge­ogra­phies, do­mes­ti­cally and in­ter­na­tion­ally. We’re also ad­vis­ing oth­ers that al­ready ex­ist. We do it in Brazil, we do it in South Korea. We call that repli­ca­tion, right?

On the other side is how do we help peo­ple with­out it be­ing bricks and mor­tar? That’s in­no­va­tion-in science and tech­nol­ogy, which could be new de­vices in care de­liv­ery. We’ve had a num­ber of startup com­pa­nies and li­censes that came out of HSS, either in­de­pen­dently or in part­ner­ship with an­other or­ga­ni­za­tion.

One ex­am­ple is a re­la­tion­ship with a Ger­man com­pany that is us­ing our knowl­edge to hope­fully de­velop a new drug for rheuma­toid arthri­tis and lu­pus. An­other or­ga­ni­za­tion that grew out of HSS is an ar­ti­fi­cial in­tel­li­gence com­pany that will be able to di­ag­nose im­ages ac­cu­rately with­out hu­man in­ter­ven­tion.

HSS has some of the high­est pa­tient-sat­is­fac­tion rates in the coun­try. Our net pro­moter score is 94%, which is un­heard of. We part­nered with an out­side com­pany to cod­ify the knowl­edge around how we de­liver a great pa­tient ex­pe­ri­ence. A new com­pany was cre­ated to do that, and it’s work­ing with oth­ers.

A com­pany in Italy ap­plies ad­di­tive man­u­fac­tur­ing tech­niques, sort of like 3-D print­ing, and uses tra­bec­u­lar ti­ta­nium to make joints in a way that tra­di­tional man­u­fac­tur­ing can’t do.

We’re no dif­fer­ent than any­one else. We get paid for what we do, so we want to fig­ure out how to get paid for what we know, and use that eco­nomic foun­da­tion to con­tinue to fuel the aca­demic and re­search mis­sion of the or­ga­ni­za­tion in an en­vi­ron­ment where re­sources are con­strained. That’s the ap­proach we’re tak­ing.

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