CODE speaking with Dr. Kevin J. Bozic, MD, MBA at the 4th Interdisciplinary Conference on Orthopedic Value Based Care 2020

Session Topics:

  • VBC: Multidisciplinary Stakeholders Panel
  • 2020 CMS Updates: Think Election

Interviewee:
Dr. Kevin J. Bozic, MD, MBA
Conference Activity Co-Director
Chair, Department of Surgery and Perioperative Care
Dell Medical School, The University of Texas at Austin

Breanna Cunningham:
Hi there! Bre Cunningham here, with Dr. Kevin Bozic from Dell Medical. He serves as the Chair at Dell Medical. We’re here at the OVBC conference in 2020 and I have the pleasure of interviewing Dr. Bozic on behalf of Dr. Kain. So, Dr. Bozic, I’d like to start with talking kind of high-level thoughts on where we’re going in the future as it relates to payment reform. So we’ve had 10 years of bundles, we’ve had some work with population health. What’s the future of this look like?

Dr. Kevin J. Bozic:
Yeah. Well, first of all, thanks Bre for having me. It’s exciting to be back at this conference. I participated every year and watched it grow and watched the enthusiasm grow. Which I think speaks to the relevance of the topics and the quality of the speakers, and so I’m really glad you’re back as well. We had a panel discussion this morning around the topic of the future of payment reform, and I really see delivery system reform and payment reform as very intertwined. And so as we develop models that incentivize coordination and integration of care to produce better outcomes at a lower cost, the payment model needs to evolve along with it to incentivize that.

I am a big believer in bundled payment models. I believe that bundled payments incentivize providers who treat conditions to come together around the management of that condition and work collaboratively to improve outcomes and reduce costs. We’ve done a lot of work in the last decade on procedure based bundles in orthopedics. And in doing so, we’ve made procedures like hip and knee replacement, very efficient and we’ve reduced unnecessary post-acute care utilization. But we haven’t done anything to address appropriateness. And so where I think we need to move now is moving upstream from procedure based bundles to condition-based bundles and we’ve put together a national coalition of payers and providers that’s working towards that goal.

Breanna Cunningham:
And now at Dell, you’ve been doing this, right? And for how long? And could you tell us how it’s going?

Dr. Kevin J. Bozic:
Yeah. So we started about two and a half years ago implementing our first condition-based bundle for hip and knee arthritis, and we have another bundle for back pain. And what we’ve learned, or a couple of things, one is, to manage a condition you need a team of people with diverse skill sets. And in our case it’s not all orthopedic surgeons, you need other healthcare professionals that bring different perspectives and expertise to the table. We’ve also found that patients really enjoy being taken care of in a team based model rather than by an individual. And it’s also much more professionally rewarding for members of the team to function as part of a team, where everyone is operating at the top of their license.

We now have two years worth of data. And what we’ve seen is, when we compare the cost of care for that condition, either hip and knee arthritis or back pain, to historical costs, we’ve been able to reduce the total cost of care somewhere between 20% and 30%. And for about 62% of our patients, we’ve achieved above a minimum clinically important difference in improvement in function. Now, we don’t have a comparison group for that because historically, no one’s measured the outcomes from the patient’s perspective. But we know that with both surgical and nonsurgical treatments, we’re able to improve outcomes with a multidisciplinary team. And so now, we’re looking through a national coalition with payers, including CMMI and other commercial payers, to work towards what this type of bundle at the national level would look like. And the good news is, there’s lots of interest from both payers and providers.

Breanna Cunningham:
So let’s talk a little bit more about that. You do a lot of work with CMS, and helping try to advance policy to make it easier and more friendly for value based care. You were just there in January and you had a really interesting tweet that said, “We did a great job, we moved the needle, but there’s still a lot of work to do.” Can you talk to me about that tweet?

Dr. Kevin J. Bozic:
Yeah. So we hosted a meeting, this coalition that’s working on condition-based bundled payments, Mark McClellan, from the Duke-Margolis Center, and I hosted the meeting. And we had about 50 people, payers, both commercial and government payers, as well as a number of different provider organizations. We had organizations that are involved in outcomes measurement, organizations that are really bundle conveners. And what we talked about, we’ve been working on this for two years now, and although the concept of bundling at the condition level, everyone agrees is a good idea, the devil’s in the details. And so there’s a lot of work to do to really define the bundle, to operationalize it, to figure out how it interfaces with other value based payment models, like accountable care organizations and like procedure based bundles, and to risk adjusting the bundle. And so that’s the work that we’ve been doing. Trying to get really, really practical.

I think all of us that are in the value based healthcare world have been quite frustrated by the slow progress of the payment model moving. And we’re quick to criticize the players, but I think that they are in a difficult position and that they’re trying to exist in multiple different worlds and their world is based on a fee for service chassis. And I think about it when we started doing joint replacements in the outpatient setting, if I was doing seven joint replacements in a day and six of them were inpatient and one of them was outpatient, I don’t want to have to go back and forth. I’m going to do all my patients in the inpatient setting until I’m ready to do all my patients in the outpatient setting. It’s inconvenient for me and my patients to go back and forth. And I think that’s the world that the payers are living in. So we need to work with them to help bridge that gap.

Breanna Cunningham:
I love that. You have some empathy for them.

Dr. Kevin J. Bozic:
Yes.

Breanna Cunningham:
So another question that I have for you, this is getting a little granular, but we’ve talked about making sure that we’re controlling costs, we talk about outcomes, but in a broad sense. This is the first time in this conference, thus far, that I’ve heard MCID spoken about. So when you define outcomes as part of your program, there was also talk about patient experience. So you’re looking at MCID, which you mentioned. What other outcome metrics are you using?

Dr. Kevin J. Bozic:
So I think it’s important that when we’re talking about outcomes, we’re talking about the outcomes that matter to patients. And so in our case, as musculoskeletal care providers, we’re treating pain, function, quality of life, and so we need to measure those things. There’s a variety of different validated tools available to measure them. And I think that we need to have the tools that are the least burdensome for both the patient and the provider, but the most discriminatory so we can determine whether or not our treatments are effective. And we also use that information to determine and help patients understand which care pathway might be the most effective for them.

So we’ve developed a tool, a predictive analytic tool, that uses the patient’s baseline information, pain, functional status, quality of life, mental health, demographic information, baseline clinical health. And based on thousands and thousands of other patients, use that information to determine how likely they are to benefit from a given procedure like surgery. These tools are not perfect and they’re not meant to be used as thresholds, “You should have this treatment if you score here or this treatment.” It’s really to inform a shared decision making conversation between patients and their providers. And it allows that conversation to be much more tailored and personalized to that patient’s circumstances.

Breanna Cunningham:
Now, are you seeing payers that are taking this data and using it as a threshold? I know that there’s some programs in the state of Michigan for example, that are using PROs in that realm. Tell me your thoughts on that.

Dr. Kevin J. Bozic:
Yeah. So I think it’s exciting that payers are starting to get interested in outcomes, and particularly outcomes from the patient’s perspective. That’s another topic that we focused on in our meeting in Washington D.C. with the payers is that they are able to accept claims data. These types of outcomes that we’re measuring don’t fit well on a claims form, and so we need to develop systems for them to be able to capture this information. But just the fact that they’re interested is encouraging. We have a long way to go. It’s always been surprising to me, that we do over a million hip and knee replacement procedures a year in the United States and yet no one thinks it’s odd that we don’t systematically and routinely measure the only thing that matters to patients. And so I’m very encouraged that payers believe that’s important. I don’t think they know how to capture the information, how to use the information yet, but they’re part of the dialogue now, which is encouraging.

Breanna Cunningham:
That is encouraging, especially with surgeon leadership helping them understand that data and how to incorporate it into their programs. Okay. So my last set of questions for you is as a patient. So how far out are you from your total knee?

Dr. Kevin J. Bozic:
I’m about two years and three months.

Breanna Cunningham:
Did you take patient reported outcomes?

Dr. Kevin J. Bozic:
I did.

Breanna Cunningham:
And did you actually fill them out?

Dr. Kevin J. Bozic:
I did. At baseline, at six weeks, at six months, and I did my most recent one within the last six months.

Breanna Cunningham:
Love it. Yeah. And how are you doing? Do you know what your functional improvement score is?

Dr. Kevin J. Bozic:

Yeah, I’ve improved. I haven’t improved to the extent that I was hoping. And I think I had unrealistic expectations, as a surgeon, for what I would be able to do function-wise with a knee replacement. But I’ve definitely improved over where I was at baseline. I’m now able to walk 18 holes of golf. I could have never done that before I had my knee replaced. I’m able to hike with my family. I get pain almost every day, and it’s given me a new perspective and empathy for my patients, and it’s allowed me to be a lot more realistic with patients about what they can expect. Because I think that as physicians, and surgeons, who are very enthusiastic about what we can do for patients in terms of these life changing treatments, sometimes our enthusiasm, we get a little overzealous in how we describe the potential outcomes.

Breanna Cunningham:
Wow, that’s so interesting. So you say the results have not met your expectations. On like a zero to 11 point scale, what would you rate it?

Dr. Kevin J. Bozic:
Well, I think objectively, it’s probably an eight, but I think I was expecting an 11.

Breanna Cunningham:
Okay. There you go. I love that. I will say, I’ve seen you speak a lot and you’re a pacer. You like to move when you’re talking, and you were pretty gimpy for a while there, Dr. Bozic.

Dr. Kevin J. Bozic:
Hopefully, that’s gone away.

Breanna Cunningham:
Yes. You’re gait was lovely.

Dr. Kevin J. Bozic:
Although I still get a lot of comments about it.

Breanna Cunningham:
I’m sure. And well, it’s part of your story and you’re open to sharing it. So thank you so much for your time today, Dr. Bozic. I look forward to attending your session later on in this conference.

Dr. Kevin J. Bozic:
Well, thanks for the opportunity and look forward to another productive and successful conference this year.

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