CODE speaking with Dr. Michael Suk MD, JD, MPH, MBA, FACS at the 4th Interdisciplinary Conference on Orthopedic Value Based Care 2020

Session Topics:

  • Myth busters in Anesthesia and Orthopedics
  • Payers Perspective on Value-Based Contracting

Interviewee: 
Michael Suk MD, JD, MPH, MBA, FACS
Chief Physician Officer, Geisinger System Services
Chair, Musculoskeletal Institute & Department of Orthopaedic Surgery
Geisinger Health System

Breanna Cunningham:
Hi there, this is Bre Cunningham at the OVBC conference 2020. I have the pleasure of interviewing Dr. Suk on behalf of Dr. Kain. So Dr. Suk, as I was writing down your information, I really was hoping that you were a hand surgeon because I have some carpal tunnel after that. Holy smokes! You have a really interesting background and a lot of acronyms behind your name.

Dr. Michael Suk:
Thank you.

Breanna Cunningham:
Tell us how you got in your role as the President of Geisinger.

Dr. Michael Suk:
So, I’m the Chief Physician Officer at Geisinger for System Services and I’m also the Chair of the Musculoskeletal Institute, which comprises a number of different service lines within musculoskeletal health including orthopedic surgery, physical medicine and rehabilitation, all the therapies, etc etc. So, I really occupy two (2) roles at Geisinger. One (1) is to run a very large clinical department as well as on the hospital side, helping to manage as the clinical champion for a $1.5 billion dollar supply chain and pharmacy services. So, it gives me a little bit of different insight in terms of what is overall value based care in not just orthopedics, but really just in general for healthcare.

Breanna Cunningham:
Sure. Now, as an Orthopedic Traumatologist, did you start out operating and then just have interest in this subject or did you always have a dual-track mine of I’m really interested in the business side of healthcare as well?

Dr. Michael Suk:
That’s a great question. So, as you know, I have a Law Degree. I also have a Master’s in Public Health and a Masters in Business Administration, which I think the value of which is far more than just the degrees or the amount of study. But I think it’s reflective of maybe my interest in the overall way that healthcare was delivered. But at the same time, I also have a very burning desire to be at the top of my field in the clinical realm, so as an Orthopedic Traumatologist. And so, how you merge the two has been an interesting journey going forward. And I guess the best way to look at it is I love taking care of individual patients, particularly traumatically injured. I like to specialize in the complex revisions and the things where things go wrong for other people and try to save those, while at the same time really looking at a more holistic way in the way healthcare is delivered to try to make the system better. And to try to create what everyone’s calling value in a system that’s very disjointed. And so, all those interests combine in the current role that I have.

Breanna Cunningham:
So, so much of the work that’s being done with value and bundles and population conditions specific management is related to elective procedures.

Dr. Michael Suk:
Yes.

Breanna Cunningham:
So, you’re a trauma guy and you also just said you like to do the complex cases, the revision cases, and typically someone that’s part of a bundle shies away from those. So, can you tell me some of the work that you’re doing in your role with trauma bundles and the nuances of that?

Dr. Michael Suk:
Sure. That’s a really great question and a great insight because when we started this journey around bundles, we tried to pick those episodes that were really finite and relatively easy to control. And so, total joints became the poster child for doing bundles. You have a fairly standardized way you do things, fairly standardized in terms of the way you postoperatively treat these patients. Trauma on the other hand is very different, you don’t know what you’re going to get from day to day. And at the end of the day too, they all have very different responsibilities, very much far less predictable. So, the issue on trauma bundles is more so about looking at the total cost of care related to a condition. Let’s say hip fractures, which is a form of trauma. And is there a way for us to create certain algorithms to create surrounded by the best evidence, to then say then we’re going to execute on these protocols every single time. And then we’re going to overlay a cost analysis to see if we can do it within a reasonable sense of cost.

So, you maximize the outcomes by best evidence and you decrease the costs, and now you’re talking about increasing the value for hip fractures. And that’s the birth of things like geriatric fracture programs and things like that. So, what we’re doing now is not only focusing on hip fractures, which was I would say the easier side of the fracture world to do this. As close to as possible as a joint bundle, to now looking at greater, more complex areas. So, is it possible for an infected tibial nonunion to be bundled? And the answer is maybe, but the only way you can do that is if you’re able to have insight and control over the means of production throughout that episode of care.

So, from the preoperative testing, do we do certain evidence-based testing to make sure that we understand what we’re getting into on something a complex non-union? To the postoperative protocols, which would include a patient compact where they’re engaged and also involved in the care themselves. So, things like smoking cessation after surgery or before surgery. So, a lot of the lessons we’ve learned for total joints, I think can be piecemeal accounted into a trauma world to create a totally new animal. And I think that’s the exciting thing. And we have at Geisinger now a bundle around hip fractures, so they guarantee the care. We’re looking at wrist fractures, rotator cuffs. Well again, tibia fractures, and I think in the periphery-

Breanna Cunningham:
What about the nonunion that you just described?

Dr. Michael Suk:
And the nonunion that…

Breanna Cunningham:
So, you’re doing it.

Dr. Michael Suk:
Yeah, we’re looking at how we can apply the same principles that we’re doing and really tackle some of that complex care. Just as an aside, our first entry into the complex side was really on the joint side. So we, as you may know, have partnered with an industry partner to share risk on some of these episodes of care. So, in 2017 we launched the world’s first lifetime guarantee around a total hip surgery. And 2018 we launched the first lifetime guarantee on a total knee, the primaries. This year in January, we launched the world’s first lifetime guarantee around a revision total-

Breanna Cunningham:
When was this?

Dr. Michael Suk:
January this year.

Breanna Cunningham:
And how’s lobbying? You’re two months in, right?

Dr. Michael Suk:
I’m sorry. January of 2019.

Breanna Cunningham:
Okay, 2019. So, you’re a year in and how’s it going?

Dr. Michael Suk:
It’s going great. So, no complications, the patient is extremely happy. So, we have some patients out there today, three (3) patients who can claim that the world’s first of something that the world has never seen. And this March we’re looking to launch a couple of new exciting items around these episodic warranties that are going to be really fantastic.

Breanna Cunningham:
Can you give a sneak peek or not yet? You can do it?

Dr. Michael Suk:
So this March, I’m hoping that we’re going to announce a full all-comers, no restrictions to your guarantee on every total knee that we do.

Breanna Cunningham:
Wow.

Dr. Michael Suk:
Yeah.

Breanna Cunningham:
That’s incredible.

Dr. Michael Suk:
Yeah.

Breanna Cunningham:
I love that. You guys are doing so many innovative things and I think one thing that positions you so uniquely is that you have access to all the data points, right?

Dr. Michael Suk:
Yes.

Breanna Cunningham:
Because there’s no middleman in there, which I think I love what you guys are doing and it’s going to be fun watching you innovate. And I’m sure a lot of people will follow once you’ve. There always has to be an early adopter.

Dr. Michael Suk:
And I think that on that note it’s actually fun to be at the front. It’s also scary sometimes. So, I’m very lucky to work in a system that allows and accepts a little bit of risk taking if it’s for the right purpose.

Breanna Cunningham:
The revision thing is crazy, you realize that?

Dr. Michael Suk:
Yeah.

Breanna Cunningham:
But I love hearing-

Dr. Michael Suk:
Why not?

Breanna Cunningham:
Why not, I’d love it, one (1) year into it. So, I’m going to shift gears a little bit.

Dr. Michael Suk:
Sure.

Breanna Cunningham:
We’ve talked a lot about costs here at this conference and briefly touched on outcomes. You in some of your panel discussions brought this up. You’re the author of two PRO books, so you were always interested in the science behind the tools, how do I understand that? But you made a comment in one of the panels regarding patient expectations and I would love to hear more about that and the difference between a validated survey tool, patient experience, and what you believe are the metrics that need to be incorporated into bundles.

Dr. Michael Suk:
Yeah, that’s a great question and I think it goes back to the origin of the books and why I choose to focus on patient reported outcomes. So, the first book was written in 2004 and I joked at the panel today that we sold almost no copies. It was me and my mom. And part of the reason why is because I think PROs are still a relatively new concept. The motivating factor behind it was really pretty selfish. It was based on the fact that when you were reading for evidence based information, all of the evidence would cite some random patient reported outcome or some outcome measure. And then lo and behold, every conclusion said everyone did excellent and you’re like, “I don’t even know what they’re measuring against.” So, the books were designed to help us make some sense out of all of that.

The second edition in 2011 and we are now looking at a third edition, but over time PROs is still not a very sexy concept. It’s the routine, and as Kevin Bozic on the panel today said, “We’re really not doing a great job of collecting them.” So, we have an interest issue and we have a collection issue. Although, we think that the PROs which are reflective of patient-reported outcomes are very important. So, if that is all true, then I think the next stage and where we need to go is not only to find out what their opinion is, but I think it morphs into, is very directly related to what is actually important to the patient. Is it important that the patient reports a 75 on the KOOS score? Well, you’d ask a patient, they didn’t know what the heck they were filling out and it means nothing.

Is it important for surgeons to compare themselves based on a KOOS score? I got a 76 you got a 74, I must be a better surgeon. These are not really reflective, I think, of what’s really happening in healthcare from a patient or a consumer facing perspective. And so, I’ve been a proponent of looking at using those tools but then enhancing it by cultivating and capturing something called patient satisfaction. And that satisfaction measure I think is reflective, not only of the patient reported outcome, the tool and instrument, but it’s also reflective of how we set patient expectations before surgery, right? And then, at the end of the day we asked the critical question, are you happy with what happened? And it’s the world’s simplest questionnaire.

Breanna Cunningham:
How do you like to ask it? From the answer option, do you do a five point Likert or do you do a net promoter type score?

Dr. Michael Suk:
It is a yes or no binary answer.

Breanna Cunningham:
Really?

Dr. Michael Suk:
Are you satisfied with your care? And if the answer is yes, then you should feel good about an x-ray that may not look perfect or you may look if your KOOS score is 65. Because you put those two (2) together, what’s really ultimately important is that in the patient’s particular condition and in the patient’s individualized overall context, they’re pretty satisfied, and that’s what we’re here to do, right?

Breanna Cunningham:
Sure.

Dr. Michael Suk:
We shouldn’t be setting up, I think, a comparable contrast type of situation on metrics that are really meaningless from the patient’s perspective. And I don’t know how far I’m going to get with these arguments because I’m one who’s been proposing that we continue to measure, which I think are very important and it’s really an important part of the journey. I think it’s now time to overlay something that’s pretty critical.

Breanna Cunningham:
That makes plenty of sense. Absolutely, and I would agree as someone that has an outcomes data registry, that question, have the results met my expectation and would I do the surgery again, are two extremely powerful indicators, particularly over time.

Dr. Michael Suk:
That’s exactly right. And I’ll just add one other thing that as we look toward the future… So, I recently gave a talk about patient reported outcomes and why we at Geisinger were one of the first to integrate them directly into our Epic database. So, we use a number of different softwares to capture outcomes across all musculoskeletal conditions. And it’s not because I want a pretty dashboard or I want to go into my EMR, it’s because I think the future will be very telling, in the sense that if I can match an outcome score with all of the data that I have in any EMR. So, for example, I just did a patient who’s a BMI 30, she’s a mother of two, she’s never taken opioids a day in her life, she’s never smoked, but she has a history of slight depression, has been on an antidepressant, and she walks four miles a day. And by the way, because we collect this information, we have her genomic code built in by EMR. So, I do her surgery and she comes out and she has a PRO score of KOOS of 65. So, in the future with this database I can say, and the next patient I get who matches that profile, more importantly, I can then tell them this is where I think you’re going to be.

Breanna Cunningham:
Yeah, this is what a 65 looks and feels like.

Dr. Michael Suk:
That’s right.

Breanna Cunningham:
That’s amazing.

Dr. Michael Suk:
And so, I think that’s incredible for the future… and that’s about collecting the data, putting it into some augmented intelligent format. But it starts with the data collection and it’s got to be part of what we do. And I think we have to constantly think about the bigger picture. It’s not just a checkbox. It’s actually really meaningful for the future of what we do.

Breanna Cunningham:
Absolutely. I love it. So, my final question for you, what is it that you love about Dr Kain’s conference?

Dr. Michael Suk:
So, that’s a great question too. So, I’ve been here now multiple years in a row. Number one thing I love about Zeev’s conference is Zeev. I have rarely met in my lifetime someone who’s passionate about value based care and multidisciplinary medicine, and rarely have I met an anesthesiologist who is so enthusiastic about orthopedics. I think it’s reflected in the audience, in that you have multiple repeat attenders and it’s the changing format and it’s the new ideas and the new topics that come up every year. I’ve told him this many times and I tell him to his face that he’s a real visionary when it came to this. I think he’s put together panels of people who have been successful in their own pockets of life, and they’ve put us together and we just get better. So, I learn everything… The things I think people learn from me and my experience at Geisinger, but every time I come I’m learning a tremendous amount from my peers.

Breanna Cunningham:
Sure, Dr. Vaccaro was amazing today.

Dr. Michael Suk:
Yeah.

Breanna Cunningham:
Yeah, absolutely.

Dr. Michael Suk:
And we know each other through the circles, but it gives us a chance to collaborate a little more too, so it’s really a lot of fun.

Breanna Cunningham:
He was hard on you this morning.

Dr. Michael Suk:
He was hard on me this morning. Hopefully I rebutted him pretty well.

Breanna Cunningham:
You did. Great job.

Dr. Michael Suk:
I think I snuck on the panel just to piss him off.

Breanna Cunningham:
I love it. Well, it made it a lot of fun. I sure enjoyed it.

Dr. Michael Suk:
Good.

Breanna Cunningham:
Dr. Suk, thank you so much. It was a pleasure talking with you.

Dr. Michael Suk:
Oh, great. Thank you. Thanks for having me.

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