Health policy at the American Academy of Orthopedic Surgeons. Featuring Shreyasi Deb.

Researcher Shreyasi Deb, PhD, MBA, became interested in health disparities when studying economics, and has since applied this perspective to understanding public health. At the American Academy of Orthopedic Surgeons, Shreyasi is looking at the positives and negatives of bundled payment models and the unintended policy consequences around value-based care. Are some patients already experiencing inequity and exclusion? Can we address the unique socioeconomic and multiple comorbidity aspects of each patient in a post fee-for-service world by spending more on social services? With Bill Finerfrock.

Episode Transcription

Health policy at the American Academy of Orthopedic Surgeons. Featuring Shreyasi Deb.
Published: November 1, 2019

Researcher Shreyasi Deb, PhD, MBA, became interested in health disparities when studying economics, and has since applied this perspective to understanding public health. At the American Academy of Orthopedic Surgeons, Shreyasi is looking at the positives and negatives of bundled payment models and the unintended policy consequences around value-based care. Are some patients already experiencing inequity and exclusion? Can we address the unique socioeconomic and multiple comorbidity aspects of each patient in a post fee-for-service world by spending more on social services? With Bill Finerfrock.

Bill Finerfrock: Hi, you’re listening to the Health Disparities Podcast from Movement is Life, conversations about health disparities with people who are working to eliminate them. I’m Bill Finerfrock and today I’m discussing health disparities and health policy with Shreyasi Deb. Shreyasi is the senior director for health policy at the American Academy of Orthopedic Surgeons, she’s done research in peer-reviewed publications in disability health and healthcare disparities in aging. Appreciate the time you’re spending with us today to talk about these health disparities and health policy issues. Tell us a little bit about yourself and how you kind of got into this whole area, you’re not a physician you’re a researcher, so what got you interested in health disparities in this area?

Dr. Shreyasi Deb: So, thanks Bill for having me here on your podcast. I first got interested in disparities across the broad spectrum of what we know as social services in college when I took up a course on Developmental Economics, I majored in economics. That was in India, which is a huge country, very populace but we have all kinds of disparities and a lot of diversity of issues. When I came to the United States for my doctoral degree in health policy, this was an area that really stood out for me as an immigrant, as a woman of color yet being privileged, I could see how just depending on where you live or what your resources are or how you look could sort of determine how long you would live and what quality of healthcare you can get or what kind of education you can get. So, all these things really rattled me and led to my dissertation where I looked at differences based on race, ethnicity and gender on access to primary care, on patient provider communication; very interesting so that’s how I got into it.

Bill Finerfrock: So, you’re at the American Academy of Orthopedic Surgeons and one of the things that has been going on in your area, in orthopedics in particular is looking at changing how we pay orthopedic surgeons for knee and joint replacement, how that impacts hospitals, what are generically referred to as bundled payments. There’s been a lot of concern that bundle payments might actually exacerbate health disparities, the things that you’ve already recognized under the current payment system. Can you talk a little bit about bundle payments and the concerns about what that may cause and why with regard to health disparities?

Dr. Shreyasi Deb: Yes, I would want to start with where bundle payments really work. They are one modality of value-based payment as you know, so at this time the kind of healthcare expenditure that we have in this country, one way to sort of solve that issue is to pay for value rather than volume, which we’ve been doing all along through the fee for service program. I think it’s a step in the right direction, but you’re correct until and unless we can introduce risk adjustment and I’m talking not only about clinical risk adjustment but also socioeconomic risk adjustment and it’s awfully hard to do, until and unless we do that, we’ll continue to see a lot of unintended consequences of policy as we say for example, the comprehensive care for joint replacement program. It’s CJR for short from the center for Medicare and Medicaid Innovation. It’s a hospital-led bundle program, it’s a demonstration, it’s going to come to an end in a year or so. There has already been peer-reviewed literature that shows that safety-net hospitals that care for a certain group of patients might be penalized more than hospitals that probably care for less riskier patients in the sense, who have more resources or have lower co-morbidities and things like that. So, we definitely need to have both clinical as well as socio-economic risk adjustment for these bundle payment models to work.

Bill Finerfrock: I wanted to dig in a little deeper on that, the concept of risk adjustment in and of itself is not uncommon. We’ve been doing it for a long time at an insurance company level where if an insurance company takes on a large cohort of individuals who have multiple medical conditions, we’re going to pay them a little bit more. But somehow that concept doesn’t seem to have extended down to the provider level where we’re now shifting financial risk. Is that kind of what you’re talking about?

Dr. Shreyasi Deb: Yes, I think for this to work and here at Movement is Life we talk about how there’s not one solution to these issues, we have to look at providers, communities, we have to look at policymakers, everybody has to work together to sort of lessen the disparities. I’m not even talking about removing them all together because we are sort of on that journey, but I very strongly believe that everybody has to take risks including hospitals, physicians or other kinds of clinicians. It’s a team sport, everybody has to get into the game, but as I mentioned it’s awfully hard to do. How do you scale that? And then the biases come into the picture and that’s what we see but that should not deter us that should not be a disincentive for us to move away from value-based care.

Bill Finerfrock: So you made a distinction between what you referred to as clinical or medical risk adjusting versus social risk adjusting and I think historically the medical side is where there’s been an acknowledgement that yes it’s appropriate but the social side of it, not so much. Can you talk about that a little bit and what you mean by or give some examples of those social…?

Dr. Shreyasi Deb: Absolutely, yes that’s where I think we need a lot of work right now and thanks for raising that. Let me give you an example, so total knee arthroplasty, since we are talking about musculoskeletal care, it’s one of the most commonly done procedures, not only in the Medicare population but also almost Medicare population, maybe 55 to 65 that kind of age range. Recently, Medicare decided that total knee arthroplasty can also be done in the hospital outpatient setting and it had a lot of unintended policy consequences. And we at the Academy have been working with the centers for Medicare and Medicaid Services to educate all the stakeholders involved and then one part of that education is sort of sharing illustrative case studies. So, to give you an example of a socio-economic risk factor, 65/66-year-old patients who doesn’t have clinical comorbidities, doesn’t have other chronic conditions goes in for an elective knee replacement is expected to have full recovery, very good outcomes, this person lives 10 steps up in New York City. What are you going to do? For the surgeon, the decision at that point is to probably let that patient heal for maybe a night, a day and a half at the hospital or maybe two midnights, stay at the hospital and then go home because just because of the living situation of that person or maybe that person lives by themselves and there is no family member to take care of them. Rural situation, maybe somebody who is otherwise healthy, we are talking about clinical comorbidities. Medically, that person is expected to recover quickly but they live in a rural farm and they do not have family nearby, we cannot really let them go home after something like a knee surgery, so that’s what I’m talking about.

Bill Finerfrock: So to put it into kind of economic, let’s say that patient who needs to spend an extra two nights in the hospital and just to pick a number, let’s say it’s a thousand dollars a day for a day at the hospital, you’ve added two thousand dollars of cost to that procedure and who’s paying that two thousand under fee for service, Medicare would have paid for that presumably but now the surgeon is going to be on the financial hook or the hospital is going to have to pay for that additional time is that what you’re talking about?

Dr. Shreyasi Deb: So, let’s look at it slightly differently. So, for one thing, what I gather from my research, from my look at these procedures, most of the cost is focused on the first day which is the day of surgery. And then we are probably talking about room and board and that depending on the hospital lead to a figure of a thousand dollars, let’s assume that it’s so. So that versus this person developing postoperative risks and then coming back into the hospital.

Bill Finerfrock: So, readmission.

Dr. Shreyasi Deb: Readmission or maybe depending on the time of day or what the situation is maybe coming back to the emergency department and what kind of costs are we talking about? So, we have to compare our savings to that kind of expenses which we all know are really very high. When we are trying to save that thousand dollars we are maybe putting ourselves at risk of spending way more when that patient might come back.

Bill Finerfrock: Right, one of the concerns that people have expressed is that because of the fact that the payment models don’t take all of these things into consideration that hospitals or surgeons will become more selective in the types of patients they’ll choose to take on. So, if they feel that a patient is at greater potential risk of readmission or to be more costly, they’ll simply say “I’m sorry, you’re not a good candidate,” its what people refer to as ‘cherry picking’ or ‘lemon dropping.’ Do you think that’s a real concern and what are the potential implications of that if that does come to pass?

Dr. Shreyasi Deb: Well, I would sort of divide my response into two sections to begin with, I think our physicians are all in this because they really want to see better outcomes for their patients and they’re really committed to that. And I really believe in the innate goodness of our physicians and that that’s the service that they do to all of us, to all of their patients. I think that by design I do not think physicians would likely to be selective about the patients that they see. Now, there is definitely a risk of being selective, what kind of patients that are suitable for a certain surgery, what parameters are being looked into and there I would like to highlight the concepts of equality and equity. The same size thing doesn’t fit everybody. So, can we have incentives for our physicians to look at patients who might be for example, our Dr. O’Connor talks about Faith, her patient who is obese and they have to make her lose 40 pounds to have a knee replacement surgery. Somebody like Faith, can we really have an incentive for Faith’s surgeons to really work with Faith and provide her with, a lot of times it’s just social support as we all know and Bill, you’ve been a big proponent of all the social services, so you know maybe Faith just needs some social support like the programs that we do here at Movement is Life. Those kinds of things, maybe build that into programs for example, Medicare. Medicare Advantage has been trying to help seniors with fresh food, warm food, those kinds of things, some basic help with the activities of daily living, some of which traditional Medicare doesn’t pay for. Our solution probably is focusing more on social services and we are going to save a whole lot of expenditure on the medical side if we do that.

Bill Finerfrock: Yeah, one of the situations, you mentioned Dr. O’Connor and the patient, one of the other aspects of that is, it’s one thing to tell a patient, “Okay, we’ll lose 40 pounds,” and the patient will say, “Well, how do I do that?” “Oh you know walk, every night just walk a mile or whatever, build up to whatever you can.” But if you’re an individual who lives in a rough neighborhood where crime, drugs and other things may be very prevalent, the idea of walking which seems perfectly logical perhaps to the surgeon or to the doctor is really not a realistic possibility for the patient. So, it speaks to the doctors also trying to understand the circumstances in which that individual lives and then whether it’s the doctor or the hospital kind of working with that patient to figure out all right are there other options, are there other alternatives? I think there were recently some stories about a woman who lost a lot of weight just walking in place in her apartment and but sometimes telling the patient those opportunities, those options exist.

Dr. Shreyasi Deb: I very strongly feel that the next frontier for our health policymakers should be focusing more on social services. As you know, all OECD countries spend way more on social services than they do on healthcare expenditure and we are outliers in how much we spend on medical services. We should focus more on social services and then sort of rebalance that and I think we’ll be at a better place.

Bill Finerfrock: I think you’re spot on there. Tell us a little bit more from a research perspective, are there other aspects of this that you’d like to be able to research or where you think there’s a need for some additional research to help better inform policymakers?

Dr. Shreyasi Deb: Yes, I briefly mentioned in the first discussion that we were having about patient provider communication. In my research I have seen that there is definitely better communication when a provider and patient has a racial, ethnic or gender concordance. We know that men and women approach care very differently, they talk to their providers, they talk to their physicians very differently that’s there and we need to borrow from education policy. There’s a lot of literature in how a student responds to a teacher who looks like them. How do I respond to a teacher who looks like me, speaks like me, has had lived experiences like I have had? So, I think we need a lot of research. In my research, I had limited data but I would want to expand that and see how that impacts outcomes. I did see some impact of better communication, having better outcomes and I was focusing only on mental health, but I would like to see more research on that.

Bill Finerfrock: One of the things as you know Movement is Life has been doing is working with Congressman John Lewis on some legislation, essentially saying let’s factor this into our evaluation of models and get people to build the models in such a way to proactively try to address these issues rather than looking at outcomes data three four years down the road and going, “Gee, we have a health disparities problem that’s even worse now than it was before.” Can you speak a little bit about this idea of looking at how we’re designing models and trying to build these factors into the models?

Dr. Shreyasi Deb: So, there’s the public side of things that we are going to work on with Congressman Lewis, Medicare and Medicaid models and then there are a lot of innovations also happening in the commercial insurance space. It’s no secret that it’s driven a lot by our soaring health expenditure, healthcare expenditure and everybody wants to sort of control that and yet improve quality of care. As I said, it’s very difficult statistically to really real-time study where the impact is of building in risk adjustment. But there is definitely some impact if you build in and that’s probably where the innovation center was created and was given such a broad freedom to sort of experiment. And they have these demonstration projects which are like four or five years long and then they do evaluations every year sort of to see where we are in short-term and then sort of build it out. The innovation center has been doing that because they did the bundle payment for care improvement model and then now, they have the bundle payment for care improvement advanced where they have built on their learning from the earlier model. And CJR also came in because two of the procedures I think of that, I think one was cardiovascular and the other was musculoskeletal. Lower extremity joint replacements showed huge savings in Medicare under BPCI so CJR was a mandatory model. So, they are trying to see if voluntary models were vis-à-vis, mandatory models or now CJR is a partially, voluntary, partially mandatory model. So, sort of building in those policy drivers in the model to see how things move and then, you can do those differences in different studies or natural experiments to look at outcomes.

Bill Finerfrock: From your work with those folks and seeing where they’ve made adjustments, do you feel that there’s an understanding on their part that these are serious and significant issues that do need to be addressed or they’re not just going, “Yeah, yeah that’s fine,” and giving you short shrift?

Dr. Shreyasi Deb: Yes, I was just at a national quality forum conference couple of days back and there is a huge move towards virtual care, telehealth. For proceduralists like our orthopedic surgeons it’s difficult to sort of design their practices around virtual care, but I think it’s possible and it’s coming. So, telehealth, e-health, that’s going to be hugely popular, and CM has just announced I think a huge grant, about one million dollars for artificial intelligence, use of artificial intelligence to predict outcomes. I think that’s fascinating and CMMI director, Adam Bowler was at that conference and he was saying he believes very strongly in “we get what we pay for,” so we’ve been paying for volume and we were getting volume. If we pay for value, we will get value and everybody, even those who find it harder, some of us are easier to change than others, will get on that boat and I strongly support that.

Bill Finerfrock: But I think the telehealth I agree holds a lot of promise but kind of to an earlier point you made with regard to the investment in the social or non-healthcare parts and I was talking with Dr. Huff who’s from Georgia. And when she was working in a more rural area, she said the access to the internet in those communities was not as good as it needed to be so telehealth wasn’t as readily available or as good as it could be. So, one of the things that’s going to make telehealth more accessible is improving the internet capability, the connectivity in some of those remote areas to really allow that to occur. So, it kind of speaks to the point you were making earlier of trying to develop a better healthcare delivery system isn’t focusing exclusively on healthcare and medical care but all those other things that are a part of that but not necessarily always thought about.

Dr. Shreyasi Deb: Yes, rural broadband and net neutrality, those are things people would think that’s not really related to healthcare but it is just as you laid it out, yeah.

Bill Finerfrock: There was a really neat project, I was with some folks last week about, it was a telehealth where in Louisiana they’ve approved a telehealth with a rural clinic and the schools in their parish. And they’ve put the cameras and the technology into the nurses’ offices and so if a student is sick or ill, they can go to the nurse’s office. They can have a visit with a nurse practitioner who’s at the clinic and it eliminates the need for the parents to take a day off. It eliminates the child missing school for going back and forth and go down to the nurse’s office, 15 minutes and they’re back in the classroom presuming it’s something they’re able to go back. So, yeah, I do, I mean we see examples of where telehealth really has the opportunity but there’s still some things to be worked out there. Any thoughts in terms of where you’d like to see things go or if you had the opportunity to talk to some of the policy makers to say if there’s one or two things you could do, really kind of focus in on these areas?

Dr. Shreyasi Deb: Well, this is repetitive but I will go back to asking policymakers to invest more and more on social services. Our demographics are changing, we are aging very fast and then on the other hand, the younger people, they are much more racially and ethnically diverse in this country. So, we have to look at both ends, and we have to invest more on social services than on healthcare, that’s what I always talk to policy makers about.

Bill Finerfrock: Well, that’s great. Dr. Deb, we appreciate you taking time to talk with us today. You’ve really given us some great insight and a perspective as a researcher, as an analyst into this issue and we look forward to continuing to work with you and talk with you in the future.

Dr. Shreyasi Deb: Thanks Bill, very happy to be here and thanks for talking to me.

(End of recording)

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