Round TablesPerspectivePublication Exclusive

Creating a team to navigate the modern health care environment

In the second part of this discussion, I ask panelists John W. Paul and Patrick J. DeMeo, MD, about integrated delivery networks. Here, they provide their thoughts on the essential characteristics necessary for these structures to operate in the modern health care environment and note the advantages and challenges of these solutions when applied to orthopedic subspecialty care vs. general orthopedic services. Click here to read Part 1 of this dicussion.

John J. Christoforetti, MD
Moderator

Roundtable Participants

  • John Christoforetti
  • Moderator

  • John J. Christoforetti, MD
  • Pittsburgh
  • Patrick DeMeo
  • Patrick J. DeMeo, MD
  • Pittsburgh
  • Donald Fischer
  • Donald R. Fischer, MD, MBA
  • Pittsburgh
  • John Paul
  • John W. Paul
  • Pittsburgh
  • Alan Russell
  • Alan J. Russell, PhD
  • Pittsburgh

 

John J. Christoforetti, MD:What are the fundamental qualities of an integrated delivery network (IDN) solution to modern health care delivery?

John W. Paul: At its core, a modern integrated delivery network (IDN) should provide comprehensive care and population health management by coordinating physicians, caregivers, operational and integrated financing capabilities. Ultimately, an IDN should understand community needs and provide services not only to treat illnesses, but to keep the population healthy. Patients have to come first. The patient experience is critical in modern health care delivery — from well care to sick care. The experience has to be consistent, proactive and seamless across the IDN.

IDNs have to create differentiation based on value and meet the expectations of key decision makers that include employers, payers, referring providers and consumers. For the IDN, this means providing best-in-class outcomes, data connectivity, easy access, cross-continuum collaboration and an appropriate alignment of price to service.

The IDN must continually evaluate ways to reduce the cost of health care, eliminate medical errors and offer preventative health strategies. Success requires investment in technology and population health management capabilities, an operating rigor, and quick translation of best practices and science to deliver patient-centered care.

Collaborative relationships with the community and employers are becoming more critical and continue to evolve. Communities and consumers are accessing providers directly and seeking care where it is affordable, easily accessible, safe, and of the highest quality. As stewards of community health care resources, IDNs have to be artful and nimble at investing and innovating to wisely manage resources and serve regional needs.

Christoforetti:How does the IDN environment define and foster quality beyond the financial “bottom line?”

Paul: Purchasers of health care expect quality irrespective of the IDNs financial bottom line. Today, as health care faces immense challenges — rising costs, an aging population, declining reimbursement and a fragmented system — IDNs must continually ensure high quality services to patients. Patient-centered, science-driven, high value health care is fostered through effective leaders and caregivers who remain focused on delivering services that address the overall health of the community. By taking advantage of opportunities through technology, science and medical innovation, IDNs can continually demonstrate quality and value.

IDNs should be open to collaboration with many types of providers and partners. These collaborative relationships facilitate additional and, in many cases, more rapid access to quality programs, best practices and services.

Partnerships, vision and collaboration position the IDN to serve as a pioneer for driving the future and quality of health care — continually incubating new ideas, financing models and discovery to demonstrate value.

Christoforetti: What external factors will be key to the success of an IDN?

Paul: Health care is delivered locally. To be successful, an IDN has to play an active role with community leaders and employers to perpetuate a shared vision on health care “value” and ensuring health care services meet current and future needs.

With the shift to a consumer-driven health care market, IDNs have become the subject of marketplace opinion. IDNs must monitor and be sensitive to the new logic of “choice.” For example, transparency tools that demonstrate value and provide consumer ratings are widely available — and consumers are increasingly more willing to pay for access to these tools.

At the same time, there is a growing shift to employer-sponsored coverage. Self-funded employer programs mean IDNs must be prepared for changes that will come from the continuing trend of large employers — and employer associations that are comprised of small employers — to contract directly with providers. In response, IDNs must be equipped to collaborate with these employers on “shared accountability,” comprehensive care capabilities, adequate geographic scope and unique relationships.

As more employers move toward self-coverage, commercial insurers are forced to rationalize their value to employers. As a result, commercial payers are putting pressure on IDNs to drive more health care “value.” Bundled payments to reduce cost and shift risk, as well as deployment of narrow networks to steer patients to high value providers, are examples of how commercial payers are leveraging market influence to demonstrate their value to employers and consumers.

We know that consumers, employers and payers drive significant change and are demanding transparency and more value. IDNs must anticipate and be attuned to the external factors that are impacting the way health care choice is made and paid for, such as consumer opinion and trends, community needs, political trends and the state of the local economy.

Christoforetti:Do you have any key advice for orthopedic surgeons considering modifying their practice to include participation in an IDN?

Patrick J. DeMeo, MD: I do not believe that there is any specific advice that I would give to an orthopedic surgeon when considering participation in an IDN. Participation in this type of network does not affect your ability to provide high-level musculoskeletal care to patients and, to the contrary, may actually enable us to have access to a wider array of patients in the marketplace. I believe it does have the potential to create an environment for the orthopedic surgeon in which he or she can direct a practice in more of a subspecialty manner than that of a general-type practice. For those individuals who like working within the framework of a team-oriented environment, I think this would be a rewarding experience.

Christoforetti: How does IDN affiliation preserve the ability to train orthopedic residents and fellows?

DeMeo: I believe the ability for orthopedists to work in conjunction not only with hospital administrators but also with insurance providers gives us the ability to educate them about where the hidden costs of medicine lie. This allows us to participate in the optimization of our patient care — both in the inpatient and outpatient settings. Our input is taken seriously by those individuals as we both strive for success in patient care. I believe we will see this type of consolidation in other markets throughout the country in the near future, and I think it is something that we should embrace as a logical next step in the continuum of evolving health care.

The formation of an IDN has not interfered whatsoever with our ability to train our orthopedic residents or our fellows. If anything, it has enhanced this ability, as it has given us the economic boost of a powerful insurance provider which allows us more visibility throughout the community. The educational objectives of this model have not changed, and it has provided us with abundant date for clinical and translational research studies. In addition, through the insurer, we have established a partnership with Carnegie Mellon University with an endowed research chair, one of the world’s top universities, to begin collaboration in musculoskeletal research. I believe this partnership has enhanced the academic experience because of their commitment to excellence in patient care and innovation in disruptive technologies.

Christoforetti:What challenges and opportunities does an IDN create for provision orthopedic subspecialty care as opposed to general orthopedic services?

DeMeo: Although there are always challenges whenever any two big organizations merge, I believe we have met most of these challenges with integrity, compromise and education on both sides. As far as how it affects the practice of orthopedics in terms of general orthopedic services versus subspecialty care, I believe that it enhances an individual’s ability to subspecialize in whatever their particular area of interest may be. Since we are an academic orthopedic practice with a residency program and have fellowship-trained surgeons represented in all of the orthopedic specialties, the practice of general orthopedics in the community setting is limited within our group. However, there are community hospitals that are now becoming part of the IDN in which there are orthopedic surgeons who do practice general community orthopedics. If anything, it has formed a stronger bond between our colleagues in the community and those of us in academia, as we have become their tertiary referral center for difficult cases. We have also encouraged them to participate in our educational conferences such as grand rounds or our subspecialty conferences which occur throughout the course of the week. Many of these individuals have elected to participate, and I think they have found this experience rewarding. We encourage participation with all of our colleagues throughout the system, even those who are not part of the core academic group, and we respect their abilities.

For more information:

John J. Christoforetti, MD, can be reached at 4815 Liberty Ave., Mellon Pavilion, Suite 252, Pittsburgh, PA 15224; email: info@drchristo.com.
Patrick J. DeMeo, MD, can be reached at 1307 Federal St., Pittsburgh, PA 15212; email: pdemeo@wpahs.org.
Donald R. Fischer, MD, MBA, can be reached at Highmark Blue Cross Blue Shield, P.O. Box 226, Pittsburgh, PA 15222; email: donald.fischer@highmark.com.
John W. Paul can be reached at 30 Isabella St., Suite 300, Pittsburgh, PA 15212; email: john.w.paul@ahn.org.
Alan J. Russell, PhD, can be reached at alan.russell@ahn.org and alanrussell@cmu.edu.
Disclosures: Christoforetti and DeMeo are employees of the Allegheny Clinic; Fischer is an employee of Highmark Inc.; Paul and Russell are employees of the Allegheny Health Network.

In the second part of this discussion, I ask panelists John W. Paul and Patrick J. DeMeo, MD, about integrated delivery networks. Here, they provide their thoughts on the essential characteristics necessary for these structures to operate in the modern health care environment and note the advantages and challenges of these solutions when applied to orthopedic subspecialty care vs. general orthopedic services. Click here to read Part 1 of this dicussion.

John J. Christoforetti, MD
Moderator

Roundtable Participants

  • John Christoforetti
  • Moderator

  • John J. Christoforetti, MD
  • Pittsburgh
  • Patrick DeMeo
  • Patrick J. DeMeo, MD
  • Pittsburgh
  • Donald Fischer
  • Donald R. Fischer, MD, MBA
  • Pittsburgh
  • John Paul
  • John W. Paul
  • Pittsburgh
  • Alan Russell
  • Alan J. Russell, PhD
  • Pittsburgh

 

John J. Christoforetti, MD:What are the fundamental qualities of an integrated delivery network (IDN) solution to modern health care delivery?

John W. Paul: At its core, a modern integrated delivery network (IDN) should provide comprehensive care and population health management by coordinating physicians, caregivers, operational and integrated financing capabilities. Ultimately, an IDN should understand community needs and provide services not only to treat illnesses, but to keep the population healthy. Patients have to come first. The patient experience is critical in modern health care delivery — from well care to sick care. The experience has to be consistent, proactive and seamless across the IDN.

IDNs have to create differentiation based on value and meet the expectations of key decision makers that include employers, payers, referring providers and consumers. For the IDN, this means providing best-in-class outcomes, data connectivity, easy access, cross-continuum collaboration and an appropriate alignment of price to service.

The IDN must continually evaluate ways to reduce the cost of health care, eliminate medical errors and offer preventative health strategies. Success requires investment in technology and population health management capabilities, an operating rigor, and quick translation of best practices and science to deliver patient-centered care.

Collaborative relationships with the community and employers are becoming more critical and continue to evolve. Communities and consumers are accessing providers directly and seeking care where it is affordable, easily accessible, safe, and of the highest quality. As stewards of community health care resources, IDNs have to be artful and nimble at investing and innovating to wisely manage resources and serve regional needs.

Christoforetti:How does the IDN environment define and foster quality beyond the financial “bottom line?”

Paul: Purchasers of health care expect quality irrespective of the IDNs financial bottom line. Today, as health care faces immense challenges — rising costs, an aging population, declining reimbursement and a fragmented system — IDNs must continually ensure high quality services to patients. Patient-centered, science-driven, high value health care is fostered through effective leaders and caregivers who remain focused on delivering services that address the overall health of the community. By taking advantage of opportunities through technology, science and medical innovation, IDNs can continually demonstrate quality and value.

IDNs should be open to collaboration with many types of providers and partners. These collaborative relationships facilitate additional and, in many cases, more rapid access to quality programs, best practices and services.

Partnerships, vision and collaboration position the IDN to serve as a pioneer for driving the future and quality of health care — continually incubating new ideas, financing models and discovery to demonstrate value.

Christoforetti: What external factors will be key to the success of an IDN?

Paul: Health care is delivered locally. To be successful, an IDN has to play an active role with community leaders and employers to perpetuate a shared vision on health care “value” and ensuring health care services meet current and future needs.

With the shift to a consumer-driven health care market, IDNs have become the subject of marketplace opinion. IDNs must monitor and be sensitive to the new logic of “choice.” For example, transparency tools that demonstrate value and provide consumer ratings are widely available — and consumers are increasingly more willing to pay for access to these tools.

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At the same time, there is a growing shift to employer-sponsored coverage. Self-funded employer programs mean IDNs must be prepared for changes that will come from the continuing trend of large employers — and employer associations that are comprised of small employers — to contract directly with providers. In response, IDNs must be equipped to collaborate with these employers on “shared accountability,” comprehensive care capabilities, adequate geographic scope and unique relationships.

As more employers move toward self-coverage, commercial insurers are forced to rationalize their value to employers. As a result, commercial payers are putting pressure on IDNs to drive more health care “value.” Bundled payments to reduce cost and shift risk, as well as deployment of narrow networks to steer patients to high value providers, are examples of how commercial payers are leveraging market influence to demonstrate their value to employers and consumers.

We know that consumers, employers and payers drive significant change and are demanding transparency and more value. IDNs must anticipate and be attuned to the external factors that are impacting the way health care choice is made and paid for, such as consumer opinion and trends, community needs, political trends and the state of the local economy.

Christoforetti:Do you have any key advice for orthopedic surgeons considering modifying their practice to include participation in an IDN?

Patrick J. DeMeo, MD: I do not believe that there is any specific advice that I would give to an orthopedic surgeon when considering participation in an IDN. Participation in this type of network does not affect your ability to provide high-level musculoskeletal care to patients and, to the contrary, may actually enable us to have access to a wider array of patients in the marketplace. I believe it does have the potential to create an environment for the orthopedic surgeon in which he or she can direct a practice in more of a subspecialty manner than that of a general-type practice. For those individuals who like working within the framework of a team-oriented environment, I think this would be a rewarding experience.

Christoforetti: How does IDN affiliation preserve the ability to train orthopedic residents and fellows?

DeMeo: I believe the ability for orthopedists to work in conjunction not only with hospital administrators but also with insurance providers gives us the ability to educate them about where the hidden costs of medicine lie. This allows us to participate in the optimization of our patient care — both in the inpatient and outpatient settings. Our input is taken seriously by those individuals as we both strive for success in patient care. I believe we will see this type of consolidation in other markets throughout the country in the near future, and I think it is something that we should embrace as a logical next step in the continuum of evolving health care.

The formation of an IDN has not interfered whatsoever with our ability to train our orthopedic residents or our fellows. If anything, it has enhanced this ability, as it has given us the economic boost of a powerful insurance provider which allows us more visibility throughout the community. The educational objectives of this model have not changed, and it has provided us with abundant date for clinical and translational research studies. In addition, through the insurer, we have established a partnership with Carnegie Mellon University with an endowed research chair, one of the world’s top universities, to begin collaboration in musculoskeletal research. I believe this partnership has enhanced the academic experience because of their commitment to excellence in patient care and innovation in disruptive technologies.

Christoforetti:What challenges and opportunities does an IDN create for provision orthopedic subspecialty care as opposed to general orthopedic services?

DeMeo: Although there are always challenges whenever any two big organizations merge, I believe we have met most of these challenges with integrity, compromise and education on both sides. As far as how it affects the practice of orthopedics in terms of general orthopedic services versus subspecialty care, I believe that it enhances an individual’s ability to subspecialize in whatever their particular area of interest may be. Since we are an academic orthopedic practice with a residency program and have fellowship-trained surgeons represented in all of the orthopedic specialties, the practice of general orthopedics in the community setting is limited within our group. However, there are community hospitals that are now becoming part of the IDN in which there are orthopedic surgeons who do practice general community orthopedics. If anything, it has formed a stronger bond between our colleagues in the community and those of us in academia, as we have become their tertiary referral center for difficult cases. We have also encouraged them to participate in our educational conferences such as grand rounds or our subspecialty conferences which occur throughout the course of the week. Many of these individuals have elected to participate, and I think they have found this experience rewarding. We encourage participation with all of our colleagues throughout the system, even those who are not part of the core academic group, and we respect their abilities.

For more information:

John J. Christoforetti, MD, can be reached at 4815 Liberty Ave., Mellon Pavilion, Suite 252, Pittsburgh, PA 15224; email: info@drchristo.com.
Patrick J. DeMeo, MD, can be reached at 1307 Federal St., Pittsburgh, PA 15212; email: pdemeo@wpahs.org.
Donald R. Fischer, MD, MBA, can be reached at Highmark Blue Cross Blue Shield, P.O. Box 226, Pittsburgh, PA 15222; email: donald.fischer@highmark.com.
John W. Paul can be reached at 30 Isabella St., Suite 300, Pittsburgh, PA 15212; email: john.w.paul@ahn.org.
Alan J. Russell, PhD, can be reached at alan.russell@ahn.org and alanrussell@cmu.edu.
Disclosures: Christoforetti and DeMeo are employees of the Allegheny Clinic; Fischer is an employee of Highmark Inc.; Paul and Russell are employees of the Allegheny Health Network.

    Perspective

    This Orthopedics Today Round Table discussion provides the readership with an excellent background regarding the concept of integrated delivery networks (IDNs). There is tremendous marketplace variability, and clearly, some health care delivery models work better in certain environments than others.

    Universally, however, it appears from the payer’s perspective, that the definition of quality is outcome/cost. This can be achieved in many different methods. As suggested in this discussion, bundled payments directly to orthopedic surgeon groups are becoming common and currently more than 100 different orthopedic groups around the United States participate in some type of bundled payment for both outpatient and/or inpatient care, predominantly centered on total joint replacement with commercial, non-Medicare, insurers. As noted in the Round Table, employers are seeking high patient deductible plans to reduce their insurance costs and, in some cases, they contract directly with groups of physicians and subspecialists who are willing to assume risk and offer bundled, discounted payment plans for specific procedures, essentially bypassing the IDN. Hospitals are clearly concerned with these developments since it reduces the number of lucrative primary total joint cases in healthy patients with commercial insurance and allows orthopedic groups to perform surgery at their physician-owned ambulatory surgery centers (ASCs) or specialty hospitals, which dramatically reduces the costs of care.

    In some states, orthopedic groups receive preferential referrals from payers using bundled payments due to their low cost, high quality outcomes utilizing their own ASC, joint venture with a hospital, or physician-owned specialty hospital. These relationships clearly differ from the failed capitated plans of the 1990s where risk was primarily the responsibility of  family physician groups. Because of dramatically reduced specialty reimbursements, the capitated systems eventually collapsed due to abandonment of contracts by the specialists and overspending by the family physician groups coupled with very low payment per patient per month capitated rates.

    The future of orthopedic specialists is exciting due to the many methods in which orthopedic surgeons can be reimbursed due to the vast array of ancillary service revenues available and the ability to provide value while assuming risk at a fraction of current cost. Furthermore, varied supportive relationships between subspecialists such as IDNs can secure marketshare and hopefully control future expenditures.

    • Jack M. Bert, MD
    • Business of Orthopedics Section Editor Orthopedics Today

    Disclosures: Bert has no relevant financial disclosures.