Part of healthcare reform could result in a shift from traditional fee-for-service payment models to outcomes-oriented payments or bundled payments. Payors and legislators are tired of paying for healthcare without knowing outcomes, according to Marshall Steele, MD, a board-certified orthopedic surgeon and founder and CEO of Marshall | Steele, a physician-led healthcare firm that develops destination centers in orthopedics and spine.
"Max Baucus has said he would like to end the current pay-for-performance model and Donald Berwick, MD, [nominated administrator for the Center for Medicare & Medicaid Services] has been a long-time advocate for collecting outcomes. These changes, if implemented, would have a huge impact on surgeons and hospitals. It will mean a shift in accountability to physicians, who will have to demonstrate that what they are doing is valuable to each patient," Dr. Steele says.
Establishing systems for collecting and benchmarking patient outcomes can help healthcare providers improve the quality of care they provide as well as position providers to meet the challenges and requirements coming their way as a result of healthcare reform, according to Dr. Steele. In this article, he discusses the need for patient-recorded outcomes and how healthcare providers can effectively record and use this information.
What is a patient reported outcome?
According to Dr. Steele, true patient-reported outcomes record how a patient has or has not improved following surgery compared with their condition prior to a procedure.
Patient satisfaction scores and reports of complications following surgery alone only gives a snapshot of what is really happening, he suggests. "One hospital I know of reported 100 percent patient satisfaction and proudly displayed this information on their website," he says. "However, on closer examination, the surveys for the period were only of the fifth floor, in which 4 patients that were a mix of medical and surgical cases were surveyed. The surveys were not a good indicator as to how a specific patient population was doing, and the results were not very useful to most physicians in identifying problems and improving performance."
Complications merely reflect mistakes that happen and unfortunate events that occur during or after surgery, Dr. Steele says. To use a football analogy, complications are like fumbles. Results are like touchdowns. Touchdowns are what win games. Fumbles are bad, but like complications, can often be overcome. It is also possible to have a bad outcome (no touchdowns) from a procedure with no complications (fumbles)," he says.
Why collect patient-reported outcomes?
The reasons for collecting patient outcomes are many. Here are four key reasons, according to Dr. Steele:
1. Ongoing improvement. Collecting patient-reported outcomes related to specific procedures can help healthcare providers understand and benchmark their results as well as document true outcomes months after patients leave the facility. Collecting patient reported outcomes gives you hard data that can be used to help identify areas of improvement or to tout your results and the facility's strengths, according to Dr. Steele
2. Support claims of clinical excellence. No one can support the claim of excellence purely by reduced complications alone. However, knowing the success rate of the interventions you perform and how you benchmark against others certainly can support the claim of excellence.
"Currently, physicians and healthcare facilities alike are relying on anecdotal evidence to support the efficacy of their performance. Few surgeons are collecting and aggregating preoperative and postoperative data in their patients to see if their interventions actually worked," Dr. Steele says. "No one could publish a journal study based on anecdotal evidence, yet anecdotal evidence is primarily what we provide our patients. As healthcare reform moves forward, payors will demand more evidence from providers that what they are doing is working. "
3. Provide patients with the information they want. As patients become savvier, they will want more information related to their specific condition. Knowing detailed information will be useful as patients become more sophisticated and as they shoulder more financial responsibility for their treatment, according to Dr. Steele. Collecting patient-reported outcomes will give healthcare providers an accurate picture of how patients who receive a specific surgery for a specific problem fare in their facility under their care.
This information can also be helpful for informed consent, Dr. Steele says. "Collecting information related to how your patients do after a specific procedure can help you to better educate your patients as to the realistic expectations after surgery," he says.
Speed of recovery is an area of increasing importance to patients in the current environment, according to Dr. Steele. Previously, physicians could only provide an estimate based on their anecdotal experience but could not really be accurate. "Collecting your own information helps to increase accuracy," he says. "Having patients participate in providing you with outcomes also sends the message that you care about their result. Patients appreciate that."
4. A valuable marketing tool. Patient reported outcomes can be especially useful to provide to referring physicians. "Primary care physicians may ask, 'Why should I send my patients to you?' They may be recommending patients to your competitors based solely on a reputation that may or may not be deserved. Providing outcomes to them may help them feel more comfortable about sending patients to you."It shows your willingness to be transparent. Patients often ask their primary care doctors the same questions as specialists. Providing primary care physicians with accurate information can help answer these questions," Dr. Steele says.
How to collect patient-reported outcomes
The biggest obstacle to collecting patient reported outcomes has been simplicity and expense, according to Dr. Steele. Both of these can be overcome by using simple and inexpensive technology. Here are a few of Dr. Steele's suggestions for quickly and efficiently collecting patient-reported outcomes data.
1. Collect data before and after surgery. Unlike most patient satisfaction surveys, patient-reported outcomes rely on a comparison of how a patient was doing before surgery and how he or she is doing following surgery. This information can be collected at the patient's first visit to the office. "Most doctors don't do this in any organized way that can be used to aggregate the data. Because of this, they have no ability to compare preoperative and postoperative information, let alone the ability to benchmark their data against others," Dr. Steele says.
2. Use simple, inexpensive technology. Dr. Steele notes that physicians can collect data in a variety of ways, but the most efficient way is while the patient is already in the office, thinking about the procedure. "We use hand-held devices with preloaded questions. It takes on average six minutes for 25 questions or three minutes for 12. It can be done right in the waiting room before the physician sees the patient," he says. In most cases the physician does not need to be involved.
Outcomes data can be divided into two sections. Here are a few examples of data to collect from each category:
- The quality of the result
- Pain/reliance on medication
- Walking ability/use of crutches, braces, etc.
- The speed of the outcome
- How soon did the patient return to work?
- How soon could the patient return to recreational activities?
3. Use validated standardized surveys. Many standardized surveys are available for practices to use, and facilities can adjust questions or the level of physician input needed to complete the survey, according to Dr. Steele.
4. Benchmark. Collecting patient-reported outcomes is more useful when you can compare with others and create benchmarks, according to Dr. Steele. For instance, the hand-held device Dr. Steele's clients have used can immediately download the information to a database that can generate reports regarding outcomes information. This can then be benchmarked against others. Aggregating information can also highlight any issues or areas of improvement for facilities. "The first step is knowing the end result itself," Dr. Steele says.
5. Review the results. On the patient level, Dr. Steele notes that having this information may also be used to reduce litigation risk. "Some patients are often afraid to complain to their physician if things are not going well. Not hearing any complaints, the physician may not show the proper concern. Looking back at the survey answers may prompt the physician to call the patient back to get any additional information," he says. "It has been shown that physicians who are genuinely concerned for their patients get sued less."
Learn more about Marshall | Steele.