Central Line
Episode Number: 155
Episode Title: Alternative Payment Models in Action
Recorded: February 2025
(SOUNDBITE OF MUSIC)
VOICE OVER:
Welcome to ASA’s Central
Line, the official podcast series of the American Society of Anesthesiologists,
edited by Dr. Adam Striker.
DR. BROOKE TRAINER:
Welcome to Central Line. I'm Dr. Brooke Trainer, your host, for this
conversation with Dr. Diana Mosquera, who's the chair for the Alternative
Payment Models Workgroup, a part of ASA’s Committee on Economics, and Dr. Neeju Ravikant, whose experience
with alternative payment models led to the expansion of the pre-op eval and
optimization clinic in her institution. She's also a member of the center for
Perioperative Medicine, or CPMed. I've offered here a
quick intro to the two of you and what you do, but I'm sure that our listeners
would love to get to know you better. So if you don't
mind sharing a little bit more about your role and your interest in these
alternative payment models.
DR. DIANA MOSQUERA:
Sure. Thank you so much, Dr. Trainer. So I am at
Albany Medical Center, which is a 700 bed level one trauma hospital. I'm an
anesthesiologist here. We're located about 2.5 hours north of New York City,
and we serve an urban and rural population. Um, I work a couple of hats here.
Uh, one of the hats is I'm an associate medical director for value-based care.
And what that entails is I essentially collaborate across the hospital and
really help oversee programs that tie dollars to quality or outcomes. I also look
at readmissions and essentially think about how do we prepare our organization
to take on financial risk in models that allow us to essentially earn bonuses,
etc.? I also wear a different hat as an assistant dean for healthcare strategy
and clinical transformation, and in that role, I serve as sounded like a
catalyst to help advance the projects here that help improve the performance of
our faculty. Practice on models that are tying dollars to quality and patient
outcomes, and essentially really focus on increasing access to high quality and
efficient care. And then last but not least, I'm an
anesthesiologist and I'm at a teaching facility. So I
work with residents, medical students, and the OR. I work about two days a
week. And then, as you mentioned, I work with the ASA Committee in economics,
where it's really just a group of really thoughtful, smart and talented leaders
across the US and, you know, really enjoy working with them to kind of think
about how do we educate, advocate, and really keep front of mind how different
economic topics impact our ability to really provide high quality and efficient
anesthesia care for patients.
DR. TRAINER:
And for our audience, you just heard from Doctor Diana Mosquera, and so
we're going to hear more from her on this topic in just a moment, but I want to
hear also a little background for our audience from Dr. Ravikant.
DR. NEEJU RAVIKANT:
Yes. Thank you, Dr. Trainer. Happy to meet you, Ravikant.
I'm practicing at about an 800 bed hospital in
Detroit. Our population is urban. Um, but we also have a large system that
extends out into metropolitan suburban. And we are now acquiring another large
system which will almost double our size. So we will
be expanding out to several counties in the metro Detroit area. I am a
practicing anesthesiologist. I also teach students and residents. I am the
department director, which is sort of a system department, if you will, for
pre-surgical optimization and pre anesthesia testing. And I also serve in the
role at the ASA as, as Chair of Corporate Strategy Workgroup and the Corporate
Advisory Council for the Centre of Perioperative Medicine, and I'm on the board
for AQI. That's a long way of saying that I am knee deep in the clinical
implementation of perioperative medicine, what that looks like, and we have
launched a successful, really platform. It was already in place. Of course in Covid we took a bit of a back seat, um, but
have managed to really come out swinging with buy in from surgeons, C-suite
patients, specialists here to tell all the pros and cons of that, and looking
forward to sharing boots on the ground perspective of how that works.
DR. TRAINER:
Awesome. So, Dr. Mosquera, I want to start with you. I'm going to ask you
to speak about how these alternative payment models, I'll call them APM
programs, can advance the goals of healthcare institutions and how they seek to
provide value based care for these institutions.
DR. MOSQUERA:
Yeah. Happy to speak on that. So the way that I
think about alternative payment models, or APMs, is that they're really a
stepping stone away from the constraints on fee for service and towards a more
collaborative and comprehensive care delivery model. Uh, an example that I
think is relevant to anesthesia is the work that CMS is doing, or the Centers
for Medicare Medicaid Services is doing around episode based
models, episode based models, essentially focus on discrete care delivery, such
as surgical episodes.
So one of the models that is most recent is called the
transforming episode accountability model or TEAM. And that model essentially
is an episode-based model. It's mandatory. It started in
January 1st of 2026, and it's said to cover around 740 hospitals, or about 1 in
5 hospitals in the US. The focus in that model really is how do we deliver care
in a way that once that surgical procedure is delivered and the patient is out
of surgery, how do you transition that patient back from the principal provider
to that patient's primary care? That's a key focus of the program, that kind of
transition. So there you can see how that key
component and really common theme or thread around making care more
collaborative and more comprehensive comes through. I think that this is
something that also makes sense for all healthcare institutions. You know, it
can impact important drivers of the bottom line, such as length of stay,
readmissions, complication rates, adverse events, and overall patient
satisfaction. This is something that I think is important regardless of what
type of environment you are practicing in. And these factors are really top of mind for all leaders that are essentially
looking at healthcare, um, across, you know, the spectrum of different types of
delivery models.
So in essence, I look at APM programs as a stepping
stone away from this constraint of fee for service, but also it does resonate
with general goals and the targets that that hospitals and hospital executives
are also looking at.
DR. TRAINER:
So how do these APM programs intersect with, like the broader operational
or financial goals of these hospitals?
DR. MOSQUERA:
So I think the first piece is that a lot of these
programs really have evolved to have a quality focus. So
from an operations standpoint, the quality metrics that they're going after,
they need to be pretty high level and really align with overall goals that
cross in the hospital. So things like readmission,
safety, the patient experience. And so these are
factors that in an era where patients are looking up their hospitals, looking
up their providers and their physicians, these are factors that help, you know,
across the board so they can help a consumer that's looking for a better
experience. If you have good readmission scores, if you're known to have high
quality and patient safety front of mind, these are things that help in these type of programs but also help drive that patient
satisfaction. You know, that trust and the care that
they're providing, etc.
From an operational standpoint, I think that in an era where we can all
agree that there's high demand for care, resources are definitely
limited. There's increased complexity in patients. This concept of
moving care to the appropriate setting resonates both with alternative
payments, but also with operations and finance goals of of
healthcare institutions. Alternative payment models or APMs often focus on
things like shared savings. So if you're able to come
up with workflows that can help do things like decrease length of stay or keep
a patient in the community or in an ambulatory care setting. By doing that,
you're aligning not just what the APMs are trying to get you to do, but also
the things that overall make sense for the hospital's bottom line.
DR. TRAINER:
And so what about the patients in all of this?
How how are the patients impacted with these payment
models?
DR. MOSQUERA:
Well, you now, I think that the patients are impacted in a way that, you
know, the evolution of this idea of value has really gone from just
incorporating process measures or to looking at quality, looking at safety, and
increasingly really looking at things like patient reported outcomes. For
example, in the team model, one of the measures is a measure that looks at how
patients rate their mobility and their pain levels after a surgery. And so that
shows that a lot of this, this movement sort of is taking into
account the patient experience. A lot of APMs also take
into account things like HCAP scores, which are the surveys that
patients fill out after they receive a health care service. And in that way,
they really are helping us shift this focus from getting a patient into the OR
and just do the surgery, but really thinking about how do we expand our impact
in that perioperative journey? And, you know, as an anesthesiologist, how do we
think about, in agile terms, how do we improve that patient's experience across
the board from before they go into surgery and during and after the surgery?
DR. TRAINER:
Dr. Mosquera I'm curious, is the APM models really centered more around
hospitals systems and can it be applied, and do you
foresee it being utilized and applied to ambulatory surgery centers, these
smaller surgery centers, endoscopy centers, outpatient settings?
DR. MOSQUERA:
Yeah, that's a phenomenal question because I think we use the term APMs,
but we fail to recognize that it can be used to describe many different types
of of arrangements where you're paying in a way that
is more innovative than just fee for service. So to
answer your question, yes, there are different flavors of APMs. So for example, there's APMs that are very focused on
hospitals. Those are programs that are what we call the accountable care
organization type programs that essentially look at an overall budget or cost
for a patient population, and then sort of compare your quality and if you were
able to stay within that budget. Increasingly, the centers for Medicare
Medicaid Services, which, by the way, is the largest
health insurer in our country and really drives a lot of what happens in health
care around payments, is looking to engage more specialty services. So for example, this team model is one approach of doing
that, of trying to how do you move specialty services into value? Of course, I
would be remiss to not mention primary care. So primary care has been a huge
target really for these APM models, as we know that there's a need to help
incentivize primary care in a way that helps patients get a more holistic
experience and really trying to target more of those outcomes, rather than just
paying for every single visit that they go to, you know, their
their doctor.
DR. TRAINER:
Exactly. And then bringing it back to primary care as, like the, the
center of the hub of the wheel really I think does help align patients needs and focus that patient needs along with that
payment model. So that's very interesting.
I'm going to turn it over to Dr. Ravikant here.
I wanted to make sure you have an opportunity to speak about your experience in
starting and enhancing the pre-op evaluation in your hospital. And I know you
talked about the pre-op clinic optimization program. Um, can you talk a little
bit more about what you hoped it would achieve and sketch out for our listeners
what that success looks like?
DR. RAVIKANT:
Yes, Dr. Trainer, I'd be happy to. I think I mentioned that when I joined
Henry Ford, it was right in the middle of Covid. So
the clinic was a pretty slow place. We had just a few patients. The priorities
were, as you can imagine, for a large tertiary care level one trauma center,
very, very different. But that really was an opportunity. So
I'd like to give the listeners hope that when you are in the middle of
something that doesn't exist, there's only one way to go, which is up. So what it gave me time to do with with
partners and leaders in the space was to say, what could we do in a different
way? So for example, we now, four and a half years
later, we've gone from maybe, oh, at that time, 2 to 3 patients perhaps we're
now at close to 37 patients a day and probably will be upwards of 40 to 50 once
we're at full scale.
So that is the trajectory that that is possible. But we did have to do a
couple of things in between. One of the things we had to do was say what we
wanted to achieve. We did have protocols on, um, anemia avoidance and glycemic
control. Uh, other things like cognition, identifying conditions that were not,
uh, appreciated before boarding and the implications of it not being
understood, um, such as cardiac conditions, hepatic conditions, renal
conditions, really head to toe. So we knew that's what
we wanted to do. We had some protocols about what we would do if there was iron
deficiency deficient anemia. What we wouldn't do. What would we do for A1C's or
indications of of blood sugar control that were not
appropriate? How would we handle those discussions? But the challenge we had
was, how are we going to see the patients that we want to see? So what we did, again, very close partnership with surgical services
here at Henry Ford was to create a risk stratification tool. So
it was a novel tool that stratifies both the surgical acuity as well as
different comorbidities. It scores both of them. And
the EMR that we use, Epic, will calculate a combined score reflecting where
that patient is on a risk or an acuity scale that allows us to triage the
patient to the right team. So, for example, as you can imagine, in Covid, we
did not have an opportunity to to hire and put a lot
of funds towards this. So we needed to make the most
of the team that we had. And so what the risk tool allowed us to do was to send
low and moderate patients to PAT nurses, Pre-admission testing nurses that we
trained that have been just frankly superb at understanding how to look at
patients who have lower acuity, how to look at their conditions, mine the
chart, know what to look for, know how to close loops with either bumping up to
an anesthesiologist or an APP and really creating a process for them. We then
also hired fantastic APPs and who we trained and how to manage the high risk patients. And you need this, this sort of
scalability in order to go from 4 or 5 patients to,
you know, up to 40 patients a day. So that was important. The process of how we
would identify and move patients through the clinic.
The next thing we have to do is figure out,
well, okay, we know who we want to see. We want to see all the high risk, but
how do we get them here? And that was another sort of innovative approach. And
again, in close partnership with surgical services to say, well, if a patient
is high risk, they should automatically be referred to the clinic. And that is
really what allowed us to see the patients we needed to see and not wait for a
referral or have it missed. So there was that
innovation.
And then after that, it really came pretty fast and furious because, you
know, keep in mind that along with us are surgeons having to deal with how to to live in those APMs that you heard Dr. Mosquera mention,
whether it's MIPs or value based reimbursement or
bundle payments, whatever terminology you're using, it's just a different
conversation from fee for service. So while you want
to do a successful surgery and provide that outcome, you will increasingly, as
a surgeon, have to be accountable for anemia and glycemic control, cognition, length
of stay, discharge to a long term care facility, why, for how long? So we came at the right time because their their buy in was tremendous. It was sort of, in a word, well,
I can't believe you're going to handle all this and do it effectively, keep me
on time for aborted case or if not, you're going to tell me why have
discussions and and allow me to also run my practice
and take care of patients in a timely manner. So
everything from sort of a clinical goal, operational feasibility, and a
practical lens to how things work in the OR, and as all of us know, as
anesthesiologists, there's a practical component that you have to live in.
Delaying cases, inevitably, is not going to be feasible for a perfect scenario.
There are things that you have to balance, and I think
that's why anesthesiologists are uniquely suited for this role. We do this on a daily basis. And so that speaks to sort of how we got
to where we are.
DR. TRAINER:
You know, it's really interesting. I'm thinking
about this in terms of other institutions as well, like how some of these
protocols and this risk stratification tool that you implemented can be
replicated. So is this replicable? Can all clinics
scale like this? Can you talk about that a little bit?
DR. RAVIKANT:
Yeah. I think that it is replicable and it is
scalable. I think the biggest hurdle is honestly wanting to take it on. I want
to give listeners really, again, some very deep optimism about where you sit in
the marketplace and the professional landscape right now, which is it is very
hard to deliver this with your lens. So if you are
going to step up and say, we will deliver this. And of course, if you could
show a positive return on investment, which we did, we were funded extremely
well and are outpacing projections, if you can do that as well. Um, it's quite
doable. So I think the first thing you would do is on
a smaller scale is pick a service, whether it's a high volume, short turnover,
um, service, whether it's a high acuity service, pick something that the
expertise in your practice is well suited to support. Um, talk to your partners
about, as we all know, what kind of FTE, um, dedication would you need? Do you
need APS? More RNs? Um, how to scale the visits in a way that would provide a
positive return on investment for the facility? I think it's very scalable, but
starting small is a good idea. I think you'll be pleasantly surprised with how
fast you'll grow.
DR. TRAINER:
So I'm curious, you mentioned about the ROI on this
clinic and this idea and making sure that it's funded well, and most of these
funds I'm imagining are or bundled into these episodic payment models. So how,
as an anesthesia group, let's just say that anesthesia group is a private group
that's separate from the hospital or that's separate even from the surgery
group, if the surgeon, for example, is the one getting that episodic payment,
how do you divide up that for this initiative? How does that get funded?
DR. RAVIKANT:
Yeah, that is a fantastic question. It is a mind shift, right? It's a
different perspective. It's not just that we're going to do perioperative
medicine tomorrow and that's it. You are now and will enter office-based care.
You are a clinic. So as these patients come in, you bill for those services,
just as the medicine clinic would, or a nephrology clinic, that is the revenue
that you are generating.
Now, there is also downstream revenue. If you wanted to chase that, I
wouldn't suggest that up front. But there's a tremendous amount of downstream
revenue. If, for example, you are providing key or collaborative quality
initiatives that each surgical service has. And, for example, your
neurosurgeons might have chosen anemia avoidance and glycemic control. So when you are the clinic that says, okay, this is our
protocol for, let's say, an A1C of eight or less for elective surgeries and an
anemia of, you know, it should be hemoglobin should be ten or greater. And if
it's microcytic we'll do this. And if it's macrocytic we'll do that, they are
able to use those protocols to submit proof of their participation in value based care. And there are incentives for them for
that. And you have provided that and generated revenue
based on the clinic visit. So that is one model. Certainly
downstream revenue, additionally, not only the value based reimbursement that
the surgical specialties are able to capture based on the metrics that they've chosen,
other things are also: data capture, length of stay, reduction of unanticipated
admissions. In other words, if you were supposed to go home, you did not go to
23 hour obs. If you were supposed to be admitted, you
did not escalate to ICU. So these are downstream
revenue, and there are costs attached to those that you can then provide as
your return on investment. Other downstream revenues are certainly the consult
studies and labs that you might order to support your assessment. So I hope that answers that there are many ways to go at it.
And again, best to start small and go big.
DR. TRAINER:
Yeah, that sounds like something that should entice a lot of the groups.
So how do you earn that buy in and how have you demonstrated the program's
value since it's been up and running?
DR. RAVIKANT:
So that's a fantastic question because that too is a shift in mindset. So when you are running a clinic, that means you provide a
service that is extremely quick. Your hours are not necessarily when you hit
the OR and when you go home. They might be a little past that. So you need to have engaged members that you bring on to
your team. But you are efficient. You bring tremendous insight into what's
going on, how how acute this case is. There's a
difference, perhaps, between hidradenitis excision versus one that is purulent
and causing white counts and their diabetes to skyrocket. Understanding that
clinical lens is what gives you tremendous credibility to your colleagues. They
understand that you are not going to be delaying cases for the wrong reasons.
And if you are considering it, you have that working relationship with them.
You work with them in the OR 24 seven. So your ability
to pick up the phone and speak to them about, okay, what's really going on?
It's it's a very welcome interaction, I think personally
for specialties and an or that have become siloed
sometimes due to just the nature of healthcare. And it is a collegial
relationship about how do we how do we get this done in real time with real
life sensibility?
DR. TRAINER:
So where can listeners go to learn more about starting up one of these
preoperative optimization clinics? Is there a designated place that you can
refer them to?
DR. RAVIKANT:
Yes. So the center for Perioperative Medicine, CPMed, is a very ambitious collaborative under ASA. It's
really taken off in a very short period of time. You
can access the CPMed site on ASA HQ under the
Managing Your Practice tab. That will allow you to see some of those materials.
We are developing them as we go. Certainly I'm happy
to share my contact information. Feel free to to
reach out. There is a component, I think, for our colleagues, um, where they
feel like, boy, this is probably tailored to an academic center or to a very
large group with very large resources. And we're very passionate at CPMed to dismantle that myth. There is a way to do this,
but it might be by picking up the phone and and
talking to people who are doing it. So again, happy to to
share my information.
DR. MOSQUERA:
In a similar lens, I think that if you go to the ASA website, there's the
alternative Payment Models subsection that you can find through the website,
the ASA HQ website. And there we have things like explaining what population
health is, explaining different aspects of value-based care. And we are
constantly looking to add resources to that as well as collaborate across
different committees within the ASA to find those areas of synergy that we know
exist. And as you think about how to start up the clinic, how to build a perioperative
medicine model, it's also important to know what are the
types of programs already out there for payment that I can essentially
reference as I'm trying to get that buy in from surgery, from the
administration. If you know that maybe your hospital is in some form of APM
already, that will help you essentially formulate a strategy to show how your
perioperative medicine or optimization program can help drive and align with
those goals.
DR. TRAINER:
And this has been incredibly helpful for even myself.
I mean, this is something most of us do not learn in medical school, as you
know. So having those resources, having experts like yourselves to share that
valuable information is just so helpful. And I know we need to wrap up, but
before I let you go, I'm just wondering if either of you or both of you want to
take a moment to bust some myths. Is there something about the APMs that you
want to tell your fellow anesthesiologist so that they can understand better
folks like myself?
DR. RAVIKANT:
I think that the myth not even a myth anymore, it really is a reality.
Many years ago, we talked about value based
reimbursement, that it was coming and that fee for service would go away. And
we talked about preparing, but but frankly, fee for
service was was in place. It didn't look like it was
going anywhere. Um, that is no longer on the horizon. It is very firmly here if
you look at what private payers, CMS is doing. And certainly
if you understand their the business approach as to why they would do it, it
would make sense in addition to quality care for patients. So
the myth that we could probably not do this stuff, or it's just for people who
are interested in it, I would say very squarely that that this is about the
survival of your practice, to support all the families that your practice
includes, to be able to provide care in a different way is really required.
This is an evolution that is overdue. And, um, it's going to be exciting.
DR. MOSQUERA:
You know, just to support that. I've seen that in 2023, the Health Care
Learning Action Network, it's essentially a body that surveys every year what's
going on in the insurance marketplace. And based on 2023 data that essentially
covers about 97% of the insurance market, they showed that about 60% of
payments across commercial and public payers, like Medicare and Medicaid, were
flowing through some form of either of payments tied to quality or an
alternative payment model. So I think it's totally to
doctor Ravikant's point.
I think another myth that I would like to just address is that a lot of
times we feel like we can't take on some of these roles, or how do we as
anesthesiologists, think about this new landscape? And I think that our
strength is that we, by nature, are a cross-sectional specialty. We work across
different types of surgical care, different types of providers, and I think we
can use that cross-sectional skill set to our advantage. As you you've heard
from Dr. Ravikant, a lot of the work that is needed
to succeed in any kind of alternative payment model is really all about busting
out of silos and figuring out how do we optimize our resources. And so I think that with that in mind, um, we often think that
value is this overused word similar to, I think, how we now use AI for
everything. And I think that we kind of have to step away from thinking that
value is this overused kind of theme and really embrace it, because I think
that at the core of it, you're really thinking about how do we shift our way of
thinking to really deliver care in a way that optimizes outcomes while using
either the same inputs or perhaps less inputs or resources? And ultimately,
that, I think, helps not just patients, first and foremost, but I think as
providers, as anesthesiologists, as physicians, we all walk away feeling a lot
better if we think the care we're providing is coordinated, is collaborative
versus care that feels very siloed and constrained, which is what a lot of some
of the fee for service sort of based models offer.
(SOUNDBITE OF MUSIC)
DR. TRAINER:
Absolutely. And that's such a great way of of
putting it into perspective. So I just want to thank
both of you so much for joining me today and helping to enlighten our listeners
as well. I certainly learned a lot. I'm sure our listeners did too. So Dr. Ravikant mentioned where to
find the CPMed page, but you can also find the APM
info under the Managing Your Practice tab on asahq.org. Please come back soon
for more central line.
DR. MOSQUERA:
Awesome. Thank you.
DR. RAVIKANT:
Thank you.
VOICE OVER:
ASA's leading coding and billing resources belong in every anesthesia practice, and can pay for themselves by sharing appropriate
payment for each procedure, improving compliance and reducing time spent
resubmitting claims. Order your 2025 copies of Relative Value Guide and
Crosswalk now at asahq.org/coding.
Subscribe to Central
Line today wherever you get your podcasts, or visit asa.org/podcasts
for more.