A Spinal Shift

Elyas Bakhtiari, for HealthLeaders Magazine , January 13, 2009
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"One of the things the C-level folks should be aware of is that as you are trying to maximize efficiency, patients might start feeling rushed," McKinney says. "Patient satisfaction, as a discharge indicator, might have to be monitored very carefully. Patient education on outpatient is key in order to ensure patients are prepared for discharge in a timely fashion."

The patient navigator helps both efficiently move the patient through the system and manage patient expectations.

Because spine care relies on a significant chunk of nonemergency elective procedures, patient satisfaction can be important in a competitive market, says Franz, whose experience as a patient has given him a unique perspective on the process. Customer service has been one of his top priorities since joining the Texas Back Institute as an executive.

"It's a way to differentiate yourself," he says. "We looked at processes and flow of patients, whether they understand what they need next, and physically changed the layout of the clinic to accommodate a flow that would give patients everything they need from the time they arrive to when they leave."

Success Key No. 4: Ignore geographical limitations
For the spine center that can successfully distinguish itself, there are few geographical limits to growth. Many hospitals and medical groups have a national, and in some cases international, reach, bringing in patients from outside the local market for surgery.

Franz compares the trend to destination facilities in other service areas, particularly cancer care. "If you or a loved one were to be stricken with cancer, you might get some local opinions, but your mind goes to MD Anderson or a leader like that in the field. You know they're the best," he says. "In spine, the same opportunity exists, and no one has established themselves yet as the equivalent of MD Anderson."

Spine centers across the country are trying to fill that vacuum by not only improving quality and building solid reputations, but also through aggressive marketing and branding campaigns. As part of its strategic marketing process, UCSF identified moderate and highly complex severity of illness procedures as the most profitable to its spine care line. The organization's conclusion for how to target expansion of those procedures? Go international. "The international and national patient population would have the more complex patients coming to UCSF and also be the truly self-pay patients," McKinney says.

UCSF is in a unique position to capture that market because of both its coastal location, which allows it to capture inbound medical tourism, as well as its size as an academic medical center. It is able to tap a network of international liaisons that maintain connections in embassies across the globe to further expand its market.

Success Key No. 5: Centralize services
Most of the keys to spine care success—physician alignment, patient navigation, branding and reputation, quality of care—are significantly easier when services are consolidated under one roof, says Johnson, who is currently developing a "spine-care hospital" as a joint venture between Alegent and affiliated medical groups. "Number one, it's a physician alignment issue. Number two, it's a quality-of-care issue. We can provide the best quality of care and have the best outcomes if we consolidate in one place. Three, the market forces us to take a look at this opportunity because of physician competition in the market. We have so many physician ventures, whether ambulatory surgery centers or their own surgical hospitals outright, in our area," says Johnson.

Is a separate centralized building necessary for spine care? Technically, no. Unity Health, a 681-bed healthcare network serving Rochester, NY, launched a spine care program late in 2008 that operates out of a "virtual center"—patients are triaged based on spine care protocols to the appropriate provider.

Although a virtual center is feasible, it is not ideal and may require sending patients to different locations, says Joyce Zimowski, senior vice president of 321-bed Unity Hospital in Rochester, NY. It may be a good approach to get a service line up and running quickly, because capital investment is minimal with no new infrastructure to build. To thrive, however, centralization is important. Unity Health is in the planning phase for a spine center to open in 2010 to help consolidate major back surgeries and noninvasive procedures under one roof.

Elyas Bakhtiari is an editor with HealthLeaders magazine. He can be reached at ebakhtiari@healthleadersmedia.com.
Potential for gainsharing?

Gainsharing seems like a natural fit for spine care—hospitals are interested in controlling device costs, and physicians with the right data and financial incentives can make that happen. But the legality of these programs remains unclear, so most providers are waiting for a green light before proceeding.

Although not there yet, that green light may not be too far away. In an August 2008 advisory opinion, the Office of Inspector General approved the first spine care gainsharing project between a medical center and two medical groups, one orthopedic and one neurosurgery. The physician groups worked to standardize the use of certain spine fusion devices and supplies where medically appropriate, and the medical center agreed to pay the physicians a share of the first-year cost savings.

Although this was a first for orthopedics and neurosurgery, the OIG has approved nearly a dozen similar gainsharing projects run by the same consulting company, Goodroe Healthcare Solutions, LLC. So while the advisory opinion doesn't clarify whether other models would be acceptable, it does hint at a more permissive approach to gainsharing in the future.

Source: Advisory Opinion No 08-09

Pain management

One of the big challenges in spine care, particularly with certain surgical procedures, is measuring outcomes effectively. Researchers have raised questions about whether surgical intervention is any more effective than nonsurgical approaches for some cases, and patients don't consider a structural spine improvement successful if it doesn't alleviate the pain.

"Our expectation is that there will be a fair number of patients with chronic back pain that we won't be able to cure," says Joyce Zimowski, senior vice president of 321-bed Unity Hospital. For these patients, managing expectations and improving pain management are important, she says. Hospitals don't do a great job of managing pain, regardless of the condition—studies show one-third of patients feel their pain isn't well controlled.

If patients are educated throughout the process so they have realistic expectations, they're more likely to be satisfied even if some pain lingers, Zimowski says. But spine care continues well after an operation. "What we've been looking at is working with behavior health programs to help people live with the pain they have, and we'll be following all patients for at least two years."

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