Risk-based orthopedic care: a logical next step
Duncan Sibson, Krish Maypole
Orthopedic care is consistently a top driver of healthcare costs, making up 17-21% of total spend for payers. In our healthcare system, people who need orthopedic care cost 2.2x more than the average person (Icon Health internal claims data analysis). As is the case throughout the system, however, more dollars spent don’t translate to better outcomes.
The fee-for-service healthcare status quo often fails people in categories like orthopedics, who need lots of specialty care. In the current system, these people need more frequent care, which leads to lots of services, and lots of fees. Moving forward, high-quality care from specialists should be affordable and high-touch.
Slowly but surely, we’re experiencing a movement away from the traditional fee-for-service paradigm, moving instead toward value-based care, in which healthcare organizations are accountable for both healthcare cost and quality, and often take on financial risk.
As large, primary care-focused organizations start taking on risk for broad populations, there are opportunities to share that risk with specialty groups that provide care to high-cost subpopulations. So far, groups providing care to high-cost subpopulations have had the most success in kidney care and cancer care, tracking with some of the existing value-based care infrastructure and programs (including Kidney Care Choices and Enhancing Oncology Model).
These subpopulations tend to be small and extremely high-cost. In addition, specialists tend to take over as the decision-makers for people in these subpopulations rather than primary care providers. Other opportunities exist to support high-cost subpopulations that require a substantial amount of specialty care, with near-term opportunities in orthopedics, gastrointestinal, and cardiac care.
Value-based orthopedic care has been around for a while, primarily in the form of bundled payments for discrete, procedure-triggered episodes. CMS started the Bundled Payments for Care Improvements (BPCI) initiative in 2013.
What’s next for value-based orthopedic care?
So much more than bundled payments. More than 70% of people in orthopedic subpopulations need care from multiple specialists. Effective care coordination between all providers involved could go a long way toward preventing duplicative treatments, conflicting guidance, and general confusion, whether surgery is a part of the puzzle or not.
Icon Health delivers full-risk, comprehensive orthopedic care management for forward-thinking value-based care organizations. For all people with orthopedic conditions, we provide access to end-to-end support, from diagnosis to recovery.
Existing solutions add value to narrow stages of the orthopedic care continuum. But innovation within orthopedic care is only possible with a comprehensive, value-based approach, along the lines of risk-based specialty care models that have previously found success. Unsurprisingly, orthopedic care management has been linked to improved outcomes.
Icon Health ensures appropriate diagnoses, facilitating smooth transitions between primary and specialty care for people moving through the evidence-based care pathways that we develop in close collaboration with providers. More complete orthopedic care is the best way forward for patients, providers, and healthcare organizations alike.
