Episodes of Care: You have got to be kidding

27 May Episodes of Care: You have got to be kidding

Episode (ĕp‘ĭ-sōd‘) n.

1. A portion of a narrative that relates an event or a series of connected events and forms a coherent story in itself.
2. One of a series of related events in the course of a continuous account; An incident that is part of a progression or a larger sequence.

As I have referenced many times on this blog (here, here, and here), I am a big fan of the concept of Episodes of Care (EOC). I believe EOC’s are the best comparative and most functional unit by which health care value (outcomes/price) can be appropriately measured. An EOC can be defined as the set of services required to manage a specific medical condition over a defined period of time.

In the case of a right hip procedure, an EOC would include the pre-surgical evaluation, the actual surgery, the anesthesiologist, the operating room, actual hip device, post op recovery, medication and supplies, rehabilitation, and followup visits to orthopedic surgeon and primary care all bundled together for a single price. In the case of more chronic care, it would include all the care required to manage a typical diabetics care for a year. This would include the various visits, consults with nutritionists, podiatrists, ophthalmologists, primary care and related specialists.

The concepts of EOC have been around for a while, and the idea of reimbursing for care in this way is picking up momentum. This is an important ideologic transition, moving from providing fee for service pay for procedure mentality to a more comprehensive, wholistic approach to deliverying care. It also speaks to a fundamental problem of creating a retail health market and organizing health care into a service-based “product” that consumers can compare, shop, and purchase.

We are beginning to see the first “demonstration” projects that focus on the retail productizations (based on EOC) in Carol.com and payment mechanisms like Prometheus. These early innovations in creating health care products in a retail environment remain too complex for mass adoption at this stage, but are still very encouraging.

The barriers to “productizing” health care services into EOC’s remain formidable. Case in point: my 5 year old nephew needs to have a tonsillectomy. This is a simple, straightforward, and relatively common procedure performed millions of times each year. In attempting to provide his parents with some guidance of cost, quality, and outcomes questions, we rapidly determined that it is next to impossible to find this information anywhere, let alone in a consumable form that could be used to make a rational health care decision (ie, which surgeon, what facility, what are expected costs, what is expected outcome?).

So, we determined to turn the experience into case study. I am going to help create a EOC for a <17 Tonsillectomy. Here is what I did with comments italicized:

1. Diagnosis. The recurrent ear infections, repeat strep throat, persistent snoring, and behavioral problems led to a self diagnosis by a medically savvy father. Given the certainty of diagnosis, the primary care provider was bypassed (allowed by insurance plan) to go directly to the ENT specialist. ENT confirmed the diagnosis, explained rational for bypassing confimatory sleep studies (supported by JAMA article brought in by father), and discussed surgical options. Surgery was schedule for 10 days out. This particular diagnosis seemed consistent with symptoms, with literature, and with physician advise and no second opinion was sought. Additional research on the internet confirmed above.
2. Procedure. Next was to evaluate the procedure, including asking the physician appropriate questions about the procedure, the alternative techniques, and expectations of outcome. The surgeon did an excellent job explaining the procedure and the technique, and provided some good in office diagrams and descriptions. Provider explanation of procedure was adequate and confirmed by quick online review of tonsillectomy.
3. Providers. The next process was to evaluate which providers are required to perform this procedure. This information was gleaned from the above conversation about the procedure. Learned that the surgeon, an anethesiologist, a pathologist, and the OR team is required for this outpatient, same-day procedure. Also learned that there are typically two additional followups with the ENT and an optional followup with the primary care provider as part of a reasonable post op course. Extracting this information was difficult, and required an extensive knowledge of the health care system. Providers and staff were somewhat unsettled by this line of questioning but were open to providing it when I explained that I was a cash paying patient trying to determine what the full cost of this EOC was going to be. Insurance carrier was completely not helpful in assembling the EOC, but offered to review line item detail after the fact. This obviously misses the whole point of assembling an EOC for comparative pre-event planning.
4. Facility. Same day surgical centers are typically more efficient business operations than hospitals (hence the dramatically lower pricing). I was able to obtain the acility related charges directly from the surgery center.
5. Other components. This includes medication, supplies, and other miscellaneous items that should be included in the EOC. This was also difficult to obtain, despite every component provider providing this service dozens of times each week, no one had a collective view of what is involved.
6. Pricing. Pricing information was exceptionally difficult to obtain. After 28 minutes on hold with the carrier, I was informed that they can only tell me the physician pricing – and to get that I would need a CPT code, a physician ID number, and a zip code where the procedure was being performed. I then had to chase down each individual provider (anesthesia, pathology, and surgery center) to get pricing information. Obtaining this information was exceptionally difficult – I had to repeatedly explain why I was trying to get the information, go back and get ICD-9 codes, review the insurance discount versus cash price, and be transferred back and forth between multiple administrative and billing personnel at each provider. This process will need to be repeated two additional times with two sets of different providers / facilities to have a basis of comparison.
7. Performance. Because EOC’s are a measure of health care “value” we cannot just stop at price. We need to understand the performance characteristics of the EOC along the dimensions of proficiency (how many times has surgeon done this procedure?), ratings (what have been the patient satisfaction scores for this physician?), and outcomes (what are the quality or other relevant metrics to assess outcome of the procedure?). This was by far the most difficult component to compile. Proficiency information is somewhat available through Healthgrades, ratings information remains scant, and outcomes are essentially non-existent. These are systemic problems of measuring health care value that preclude more meaningful analysis and assessment of EOC in the short term. This is a perfect, standards-based metric development activity for one of the large government sponsored bodies to undertake (NQF, AHRQ, IOM, etc).
8. Comparative Analysis. Finally, after approximately 12 hours on the phone (and the web while on hold) gathering relevant information for a simple tonsillectomy procedure, we were able to assemble a very crude EOC. We will need to repeat the process for two additional sets of providers/facilities for comparison. It was interesting to note the wide variability in pricing, the lack of performance information, and the difficulty in assembling this information which is so readily available for nearly every other consumer industry.

This case study was helpful to solidify my belief in the EOC as the appropriate unit to measure health care value. It was also instructive to more fully understand the challenges of trying to assemble an EOC, and the opportunity that exists for infomediary organizations to provide this information to consumers. Unlocking the silo’d information from the various providers, as part of a comprehensive EOC framework, could unlock significant value for patients, providers, and payors.

It just wont be that easy. No kidding.