The Role of Clinical Evidence in Value-based Purchasing
The transformation of healthcare delivery relies on clinical evidence and physician engagement to drive value in the contracting process. That’s why HealthTrust’s physician services team conducts clinical evidence reviews in product categories that have a significant impact on patient care and are physician preference items. Input for these reviews comes from a large and growing group of practicing physicians from HealthTrust member facilities. Along with our physician advisors, HealthTrust boasts a number of clinical and non-clinical advisory boards, comprised of hands-on, facility-level representatives with expertise in their respective specialty who facilitate review of products, suppliers and emerging technologies. They also provide subject matter expertise and direction to HealthTrust’s strategic sourcing team.
“HealthTrust’s clinical evidence team seeks out new evidence, especially in terms of new technologies and pharmaceuticals,” says Robin Cunningham, MSN, RN, HealthTrust’s clinical director of physician services. “We research and analyze clinically relevant information and consult with appropriate physician advisors to confirm that information, especially when it falls in a clinically sensitive category.”
Felix Lee, M.D., is a Sutter Health/Palo Alto Medical Foundation interventional cardiologist, assists in these efforts as cardiovascular service line medical director at HealthTrust. “We look at cardiovascular products such as wires, balloons and stents, review the clinical evidence on each, and present our findings to HealthTrust’s purchasing and contracting groups.”
“Eighty percent of physician decisions affect the bottom line with respect to the cost of healthcare delivery,” Lee says. “If we want to impact cost with quality, physicians must be engaged.”
His experience with HealthTrust as a physician advisor led to positive changes at the hospital where he practices—Good Samaritan in San Jose, California. This included increased physician engagement and establishing common standard protocols for his hospital colleagues. The catalyst for change centered on the hospital patient record. Working with 30 or 40 different order sets, he and his team at Good Samaritan quickly identified wide variability in how certain illnesses were treated, increasing lengths of stay by anywhere from three to 13 days. After evaluating the order sets and creating a new process to meet core measures, they were able to lower length of stay to only two-and-a-half days.
A Metric a Month
Lee and his team pick one quality metric each month, along with recent cases to illustrate the impact of divergent practice patterns on patient outcomes. By engaging physicians around their own cases and sharing best practices, Lee has seen growing adoption of this metric-a-month approach at Good Samaritan Hospital. Over two years, 16 quality metrics have dramatically improved using this methodology, he says.
HealthTrust is fortunate to have access to rich data resources, including orthopedic and spine implant registry InVivoLink, Cunningham says. “It provides important insights that help us focus on the six dimensions of healthcare quality: safe, effective, patient-centered, timely, efficient and equitable care.
“Plus,” she adds, “we have access to our members’ most recent spend, which we use to determine market share for specific devices and technology. This market share information provides value in the contracting process, which results in savings for members.”
HealthTrust member Karla Barber, RN, BSN, CVAHP, is system director of clinical value analytics for Centura Health, a 17-facility IDN based in Englewood, Colorado. Centura’s previous collaboration revealed wide practice variation in osteobiologic utilization, but partnering with HealthTrust took it one step further by unveiling multiple opportunities to standardize.
The system’s 2017 benchmarks include changing perioperative supply practice patterns, updating preference cards and reviewing the delivery model for spine care across the IDN. By working with one physician on standardizing just one type of implant and one kind of osteobiologic, the system has already identified over $1 million in potential savings.
The chief objective is to develop physician-led clinical standards of product use and incorporate them into everyday practice at Centura Health. “We are looking for workflow efficiencies and better ways to deliver the appropriate products for the appropriate cases across the system,” Barber explains.
It’s also important to look at the whole episode of care and determine how quickly physicians can return patients back to expected functionality and quality of life, Barber says.
Barber’s role is to present the best possible evidence and research to decision-makers. “Physicians are scientists at heart,” she says. “That’s why it’s important for us to gather all the best literature and analytics required to help them discuss and reach good clinical conclusions about products as inherently complex as osteobiologics. These kinds of discussions will bring about sustainable change.
“Cost and contracts are always debatable,” Barber adds. “However, by focusing on data and science, we can zero in on the most important issue: a patient-outcomes-driven healthcare product.”
Data Drives Decisions
“When you work in a comprehensive wound care center, it’s all about the data, which is constantly changing and being refined,” says Aron D. Wahrman, M.D., MBA, MHCDS, FACS, plastic surgery section chief at Philadelphia Veterans Administration Medical Center and assistant professor of surgery at the University of Pennsylvania School of Medicine. “We must be up to speed on all the scientific journals devoted to new and current research in wound care, whether it’s hyperbaric oxygen, vacuum-assisted closures or biologics. But it’s exciting to be a part of the evolving world of biologics as well as to think of ways to improve the delivery of blood factors and utilize platelet-rich plasma.”
Wahrman, who serves as a HealthTrust physician advisor, points to a whole matrix of care to consider. “Safety and efficacy are first, but there is a cost factor as well,” he says. “The value proposition doesn’t happen in a vacuum.”
Cunningham says that during a recent cardiovascular meeting, HealthTrust physician advisors identified four categories having unnecessary variation in utilization and thus an opportunity to standardize on products offering the best overall value. Before moving forward with the contracting strategy, HealthTrust’s Cardiovascular and Radiology advisory boards, the governing Supply Chain Board and the consulting HealthTrust physician advisors agreed that some of the categories held a conversion opportunity for members. Products selected for contract in these categories—carotid stents and embolic protection, peripheral angioplasty balloons, inferior vena cava filters and vascular closure assisted compression devices—met the clinical treatment needs of patients while creating value for HealthTrust member facilities.
“We define success as a comprehensive evidence review, supported by our physicians, which is helpful and meaningful to the HealthTrust membership,” Cunningham adds.