Patients want safe, affordable, high-quality healthcare and to avoid preventable harms. However, the current system is convoluted, inefficient, and transactional. Payers also seek to limit waste and standardize care, but current business models profit from transactions. Value-based healthcare aims to relate quality and outcomes to affordability via the equation "V=Q/$". However, moving to this model faces barriers around measurement, incentives, and resistance to change from entrenched systems. A new framework is needed that holistically assesses quality using structure, process and outcomes data to inform patients and drive improvements.

1. Surgical VBHC:
A perspective
Frank G Opelka, MD FACS
Medical Director

2. Value Based Health Care (VBHC):
• Patients want to know where to go to get the care they desire.
• When a condition arises, patients want help managing their condition
and to know where to find Safe, Affordable, Good, Equitable care
for their condition. They hope to trust their care team. (S.A.G.E)
• Patients struggle in a convoluted unpredictable care journey -
disaggregated, transactional, duplicative, inefficient business model.
• Patients would like to avoid preventable harms at all cost (Safety).
What do patients want?

3. Value Based Health Care (VBHC):
•Payers want to optimize care to limit harm and reduce waste.
•Payers want to measure quality for payment incentives with
limited effort.
•Payers seek to standardize care through practice guidelines and
limit customization of care to fit each patient and in each delivery
system.
•Realize payers’ business systems profit greatly from transactional,
disaggregated models – to change would be costly.
What do payers want?

4. Value Based Health Care (VBHC):
•A framework for redesigning healthcare with an emphasis on patient
goals, around the relationships between outcomes (Quality) and
affordability (Price).
•V = Q / $ is an expression of the judgment a patient places on the
relation of the quality of care for the price. (It is not a numeric
expression)
•An episode of care (such as a surgical procedure or an
acute/chronic medical condition) defines a care journey and applies a
business model which sets a price for a bundled set of services.
ACS Mission: dedicated to improving the care of the surgical patient
and to safeguarding standards of care in an optimal and ethical
practice environment.

5. © American College of Surgeons 2022– Content cannot be reproduced or repurposed without written permission of the American College of Surgeons.
• Do patients want each transaction or a single episode
which groups all the services into a meaningful
package?
• Tools exist which can create risk adjusted price
estimates.
The Price of What?
Price in S-VBHC

6. Policy Landscape:
Extremely large federal bureaucracies with hundreds of divisions, not all of which
are aligned.
ACS
Value-base
d Care
Model
Medicare
FDA
CDC
Medicare: Payment
• Quality – MIPS vs MVP
• Innovation Center (CMMI)
• Medicare Advantage (42%), ACOs (20%)
• APM – Episodes of care (Bundles)/Direct Contracting
• FFS/RVUs (38%)
FDA: Safety
• Clinical Decision Support
(Apps) as a medical device
(ACS risk calculator, CoC
Staging App)
CDC: Care Delivery/Pop Health
• Digital Guidelines
• Care Pathway Process Maps/care tracking notation

7. Policy Landscape
ACS Quality
Model ->
Verification
& Quality
Measures
Value-based
Healthcare (VBHC)
Office of Natl
Coordinator (ONC)
Structural
Informatics
Applied Informatics
Knowledge
Management
Value Based Care/Episodes of Care: V=Q/$
• Numerator = Quality (defined by ACS)
• Denominator = Price (defined by payment)
• Production cost (defined by TDABC)
• New payment models (Episodes of Care)
Technology Interoperability
• Platforms/More than EHRs
• Standards & Data definitions
• Exchanges / Translators
• FHIR/CQL/HL7
Specialty Society Role in AI & Digital Healthcare
Specialty as the content/context experts
• Clinical Decision Support (CDS)
• Cohort tracking
• Registries
• Quality reporting
• Research
Risk Calculator
Cancer Staging

8. © American College of Surgeons 2022– Content cannot be reproduced or repurposed without written permission of the American College of Surgeons.
MIPS meets the legislative demands
of MACRA, but it doesn’t meet the
standard of measuring within a true
quality program
In MIPS, individuals (not teams) work
toward getting paid, but that is not
right goal for patient-centered value
MIPS is a payment program. Does it
help a patient find safe, affordable,
good equitable care? No!
CMS’ “MIPS THINK”

9. Most payers take a transactional approach to use quality metrics as a payment incentive
program. CMS applies a large library of measures across 24 different payment programs.
This fails to create alignment in care delivery and focuses efforts on payment. It is costly
and burdensome to administer with little ROI for quality.

10. © American College of Surgeons 2022– Content cannot be reproduced or repurposed without written permission of the American College of Surgeons.
Hypothesis:
Use performance measures for audit/feedback, tie to
payment/compensation, publicly report, then quality will get
better
Why has there been a slow transition to SVBC?
Failed to create a shoppable, competitive, ever-improving market.

11. It is time to rethink the value proposition.
Episodes of Care
1. Numerator – ACS Quality Model
• ACS Verification opportunities/barriers
• PROs – challenges and barriers
• Sandbox for pilot tests: ACOs and CMMI
2. Denominator – Price
• Legislative overview
• Operational possibilities and barriers
Verification Standards
1. Does the care team
have the right
structures & processes
for the type of care?
2. Can the team identify
when it has a problem?
3. Can they fix it?

12. © American College of Surgeons 2022– Content cannot be reproduced or repurposed without written permission of the American College of Surgeons.
New Hypothesis:
To drive real improvements in care we need a new framework:
Must appreciate and incentivize all the components of a comprehensive
quality program—high value process, structure, resources, data, event rate
monitoring, patient reported outcomes
Aligns with Domains of Quality:
safety, effectiveness, efficiency, equity, patient centered, timely
We Need a New Hypothesis/Framework

13. © American College of Surgeons 2022– Content cannot be reproduced or repurposed without written permission of the American College of Surgeons.
Redefining the Numerator (Quality) Overview

14. © American College of Surgeons 2022– Content cannot be reproduced or repurposed without written permission of the American College of Surgeons.
“Value” in health care defined in terms
of results that matter to the patient
Meeting the patient’s needs, including
individual goals and expectations, is
central to determining value—this
requires the patient’s voice
The goal for all stakeholders is to
deliver care based on what the patient
values
Patient-reported Outcomes are Central to Determining Value

15. © American College of Surgeons 2022– Content cannot be reproduced or repurposed without written permission of the American College of Surgeons.
Putting this together to move to value means 🡪 Overcoming resistance to change
• Quality has to move from being a set of disjointed metrics into a team-based
quality program which informs patients more about outcomes and safety to
avoid preventable harms. [Structure, Process and Outcomes]
• Knowledge & its management should leverage data (AI and ML) to inform
patients and care teams about outcomes, safety, price and improvement. [Find
a problem]
• Improving improvement has to incorporate knowledge into a learning
health system. [Fix it.]
• Production cost and Price Transparency are essential components of the
value proposition
• Create a market that competes and drives improvement thru transparency.
Value must take effect if it is to drive a better business model.
Transitioning to Surgical Value-based Care