CODE speaking with Dr. James R. Ficke, MD at the 4th Interdisciplinary Conference on Orthopedic Value Based Care 2020

Session Topics: 

  • VBC: Multidisciplinary Stakeholders Panel
  • Maryland’s Global Budget Program: A model for Containing Orthopedic Costs
  • The Military Health Care System as an Example of Value Based Care

Interviewee: 
Dr. James R. Ficke, MD
Professor and chairman,
Department of Orthopaedic Surgery
Johns Hopkins School of Medicine

Dr. Brian Cunningham:
First of all, thank you for a few minutes of your time. Tell us a little bit about where we’re at with advocacies specifically around orthopedic surgery and how that kind of plays into value-based care.

Dr. James R. Ficke:
Thank you, Brian. It’s my pleasure to be here. It’s an honor to be able to lead a department in an institution like Johns Hopkins. I think the ability to take that and influence care just down the street in Washington, D.C. is also a privilege. But one of the areas that we’ve really had some success, are two (2) areas. I’ll tell you the background. I was in the military for a while and as a result of that, testified to Congress about how we treat our veterans and provide some care for them and the continuity of this. But also been in the Pentagon to talk really to our nation’s leaders in the military about how the military orthopedic surgeons continue to keep their competency in the time of conflict. Those are two (2) things that I’m passionate about. But as an extension of that, working with the AAOS, the American Academy of Orthopedic Surgery, we’ve found that our effectiveness in being on the hill and talking to members of Congress, talking to even their staff is very effective. Even this year we’ve seen one from that background, the Mission Zero bill was voted into an act and is signed by the President. Also looking at some issues like surprise billing. Our patients are very surprised when they get a bill from their surgeon and then, in addition, they get a bill from the physical therapist or the anesthesiologist separate from that and not known. It becomes something that is additional and sometimes even out-of-pocket expense.

What’s been helpful is that we have an Office of Government Relations down there and we have some pretty strong opportunities to speak to members of Congress. I think all of us as professionals have that chance when we’re just thinking, we don’t have to be under the lights in D.C. to be able to do that. But what it does is it puts us at the table and not on the table. It puts us as people and when our members of Congress go to vote on issues such as surprise billing or even at the hospital-owned physicians’ issues, they don’t see us as greedy surgeons. They see us as people and they see us as people that want to take care of patients. I think it’s very easy to talk to the staff. It’s very easy to talk to members of Congress and they’re very accessible. They really want to hear from us. So it’s been a joy.

Dr. Brian Cunningham:
Yeah. Fantastic. Tell us a little bit more. You gave a great talk just recently about the payment structure in the State of Maryland and you guys have been very involved in moving this forward initially probably with some apprehension, but I think there have been some successes. For those of us that are in more traditional models, tell us a little bit about how that works.

Dr. James R. Ficke:
Yeah. In Maryland, we have an all-payer model and this is approved and known and agreed upon from the Maryland State Commission. It’s called the Maryland Health Commission and they agreed that we will take all payers at a set cost and so they’re all reimbursed. The payers pay the same bill whether the patient is covered by Medicare, by Medicaid, by Blue Cross, any of the commercial carriers, even any of the private carriers, even actually, Brian, the military. As a retiree, my Tricare benefits pay the same reimbursement to providers as Blues or private insurance. That’s been around since 1977 and has been effective to level the playing field, to open transparency and expectations as a care network. What’s happened now and since 2014, is that we’ve taken on an additional role if you will, and it’s unique in the United States and it’s called the Global Budget Revenue.

It’s a Capitalized Budget Model where the state pays us by way of support from CMS for a total cost of care across the year based on our historic market and volume. We then have to decide how that’s used and we can decide to do it on a very expensive few patients or we can do it on as many as possible who need care. That has bred for us an environment where we can look at innovation, we can look at the coordination of care. We’ve seen in the last five years increases in our out-of-hospital care, our out-of-hospital care coordination, our rehabilitation discharges, lengths of stay, it’s right up the alley of value. It is realized into value for the patients because their outcomes are better, we have access. We’ve shown data that has better access for all people, whatever their income is, whatever their racial status or their co-morbid conditions. I think one of the aspects that’s most important that we’ve seen some recent literature on published out of Maryland, is that total joint patients that are sometimes sicker, are able to get that care. So it’s actually increased access.

Dr. Brian Cunningham:
Yeah. That’s fantastic. This significant amount of cost savings that have resulted from this program, in an ideal world we would probably think about distributing that back through the healthcare system, through the hospitals, through the patients, some to the partners and stakeholders, insurance companies, etc. As you step into a new kind of evolution going forward, talk a little bit about how the sides have come together to kind of start to work a little bit more collaboratively on sharing in the benefits.

Dr. James R. Ficke:
Yeah, thank you. I expect a difficult question once in a while and let me tell you that it’s a work in progress. I think with anything new, and realize that there are three other states, Vermont, Pennsylvania, Massachusetts, that are emulating a portion of this all-payer model. I mean something similar to the global budget, but as we reach forward on something like this, it’s a learning process. What I have learned as a leader and an administrator, also as a practicing surgeon, is transparency is critical. Being at the table is critical. And in understanding, if there are savings, and by the way we’ve far surpassed what the expectation of the first five years was.

Dr. Brian Cunningham:
Yeah, three to four times.

Dr. James R. Ficke:
Yes. And so that number is valuable. Who has it is the question and how do we realize that in terms of … I think the things that we should be arguing for are savings in patient premiums.

Dr. Brian Cunningham:
Right.

Dr. James R. Ficke:
You know, Maryland has some of the most costly healthcare insurance in the country, so we should see that starting to reduce.

Dr. Brian Cunningham:
Fantastic.

Dr. James R. Ficke:
We also should see this in the hospitals too, to provide care for additional patients. We already are seeing that. But then we want to see that in terms of … The two aspects that I’m very involved with and consider extremely important are how are our physicians doing with their own wellbeing? How are they doing and wellbeing we can leave open and we can discuss it in more detail if you’d like. Wellbeing is also how they can educate and train. They came to Hopkins to be able to teach residents and we want them to be able to teach residents. We haven’t seen committed changes in the structure for resident education and we haven’t seen committed changes yet in compensation for the physicians. What we have seen is now they’re eligible to participate in the merit-based incentive programs, MIPS. I think that that’s a plus. And I also think that from our BPCI initiatives that the departments and groups can benefit if you’re in private practice as well.

Dr. Brian Cunningham:
Sure. That’s fantastic. I think the rest of the country looks to Hopkins and you and that program says you’re doing incredible innovative work and I think we’re all benefiting from the experience. I think the same can be said for Kevin Bozic and the folks down at Dell in a different way. You guys are paving the way for all of us. We’re super, super grateful and as you share this knowledge, I think you inspire other groups and other parties to try to be innovative and take the step forward. I think we’re all super grateful for that. With that, we’ll close and thank you so much for your time. I really appreciate it.

Dr. James R. Ficke:
It’s my pleasure. Thanks, Brian.

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