From AAHKS 2016 – After we stopped recording part 1, we got into an interesting discussion about orthopedic risk adjustment and decided it was worth going live again to share it with you. Full transcription is below.
Dr. Brian Cunningham: Back by popular demand: Dr. Lieberman. We’re live from AAHKS about some of the challenges and the dangers of patient-reported outcomes. Expand a little bit about what we were just talking about offline about some of the challenges associated with the design of patient-reported outcomes and the dangers of using them.
Dr. Jay Lieberman: I think dangers may be not the correct word, but there are some concerns about how the data would be used, in that patient-reported outcomes really weren’t originally developed to assess an individual patient to determine how well the surgeon was doing. They’re really developed to assess a population of patients. Therefore, you look at a population of patients to determine how well a total hip knee arthroplasty is working.
The problem now is patients want to know, or insurance companies really want to know, how individual patients are doing so they could decide either what providers to use or whether an operation is good or not. That really needs further research.
Cunningham: Do you think it’s an appropriate application to say “we’re going to follow all of Dr. Lieberman’s patients and that’s the patient population.” Then to look at how your scores are for that group rather than an individual?
Lieberman: That would be a better way to do it. One of the issues that we have now is that we really don’t have, what I would call, orthopedic risk adjustment. There’s risk adjustment for obesity and cardiac disease and things like that. But what I would call orthopedic risk adjustment is maybe the patient had prior surgery, they have an ACL reconstruction, maybe a fracture, maybe a prior osteotomy, which for the Facebook audience is when you change the angle on a joint. I’m very smooth on Facebook right now. I’m feeling the Facebook vibe!
When a patient has those type of things they may not be in the medical record. The insurance company, or let’s say CMS, that’s Medicare, can’t pull it out because it’s not part of the record. Then when you’re trying to compare different patients obviously somebody who’s had multiple prior surgeries may not do as well as somebody when you’re working on a native knee.
Cunningham: Interesting. Would you propose then kind of an orthopedic assessment based … I’m trying to think how this would work. You would evaluate a patient and take an orthopedic-specific history and then you could maybe create some type of a score?
Lieberman: What we’re trying to do now, actually it’s funny that you should mention that, although actually I led you down that pathway, is that the American Association of Hip and Knee Surgeons has actually been collecting this data and trying to work with Medicare to see how that data can be extracted from the medical record so it could actually be used to learn.
We think some of these things have an impact on outcomes, but there’s not a lot of literature to support that. That’s what we really need for that data. What’s the concern over time? Right now if you don’t do risk adjustment and payers are determining, particularly CMS, how you’re doing with them, then there would be a tendency maybe for surgeons to be concerned about doing cases that are high-risk. Obviously we want to provide access to all patients no matter what their risk is. We really need to obtain that data over time.
Cunningham: I think that gets into the the cherry picking, lemon dropping phenomenon where maybe you’re taking the best patients that are the healthiest, they’re going to have good outcomes and you’re not wanting to deal with patients that are maybe sicker.
Lieberman: Right, there are concerns about that over time.
Off Screen: Wait, what else? Anything else you want to say?
Lieberman: I think I’m done. I’m Facebook-ed out!
Cunningham: Fantastic, all right thanks again. Live for AAHKS 2016 with Dr. Lieberman.