Pearl Health Partner’s High Performance Gyn network saves payers thousands of dollars per case while providing risk protection and high quality

R Rosenfield MD

October 26, 2017.

Portland OR.

Over the past several years, there has been a push for more transparency in healthcare pricing in a market which has been largely in the dark when it comes to cost containment and strategic deployment of referral tracks that lead to cost reduction and quality improvement. The US Healthcare system is undeniably broken, but the repair may not be as difficult as many have speculated, especially within the market of surgical services, where millions of dollars are wasted annually due to inefficient utilization of resources and preventable complications.

There is no doubt that low volume “general” ObGyn physicians provide surgical services which increase the financial burden on our healthcare system.  An excess in spending results from extensive operating room times, inefficiency, lack of training and mentorship, prolonged hospital stays, and preventable complications.

The American College of ObGyn (ACOG) has been reluctant to endorse the concept of splitting Obstetrics from Gynecology into two distinct fields, despite the increasing number of graduating residents seeking fellowship subspecialty training. ACOG has a responsibility to support its membership; 58,000 general ObGyn’s who, on average, perform less than 8-10 major operations per year. This is a dilemma which has created a cultural problem of acceptance, when the market is demanding change.

Compounding the problem is current training requirements for graduating ObGyn residents to have experience in Primary Care. This concept can be confusing for patients who establish care annually with a generalist, but then feel awkward asking to be referred to higher volume surgeon when and if the need arises.

Despite multiple studies including data from NSQIP (National Surgical Quality Improvement Program) which clearly show that lower volume surgeons have more blood loss, complications, readmissions, and ultimately cost the healthcare system millions of dollars, there are few programs designed to reward dedicated surgeons willing to share data and undergo competency assessments in order to qualify to participate in innovative, cost effective, high value solutions.

More than 150 Million Americans are currently the recipients of health insurance through self insured companies. Many of these corporations are now pushing the market for change. From Walmart to Target to shared plans such as MedShare, employers and groups of like minded individuals are looking for innovative contracts with specific institutions or narrow networks looking to provide “value.”

While patients struggle to find the best solutions for their surgical needs and often fall prey to misleading marketing, third party scoring metrics of hospitals (as opposed to scoring the individual surgeon), or social media reviews, surgeons struggle to differentiate themselves from one another in a competitive marketplace. Gynecologic surgeons have been faced with major setbacks due to vaginal mesh complications, controversies on surgical approach, and the extremely volatile topic of tissue extraction.

Medicare and Medicaid efforts in women’s health have largely focused on maternal fetal care, pediatric care, and ongoing battles in contraceptive access.

Pearl Precision Surgery recognized that the dilemma in Gynecologic Surgery was significant. The only economically viable solutions lie embedded in the ACA, legislation which has been widely criticized since it’s inception in 2010. In order to enhance the earning potential of fellow surgeons, there must first be a mechanism by which savings are accomplished. If there is a mechanism by which thousands of dollars can be saved PER CASE, then there is indeed a mechanism by which those who accomplish this ought to be rewarded!

We set out to create a pathway by which we would SAVE healthcare dollars, improve quality and outcome data, and enhance earnings for dedicated network surgeons willing to subject themselves to competency assessment.

The secret to our success would be in the vetting of surgeons to participate in a Narrow Network, one with complication protection built into Bundled Episodic surgery services. The program was met with immediate success, now servicing 6 major metropolitan service areas and expanding into a national program. With hundreds of satisfied patients, preservation of reasonable margins for the facilities, and ease of managing the cases, PHP immediately prepared for growth.

With over $1.5M in cumulative savings, Pearl Precision Surgery has proven the concept and is aggressively scaling the program in the national spotlight.

Pearl Health believes that many of the current rating systems used to define high quality surgeons are disparate and rely on hospital surveys being completed in a timely matter, more so than critically assessing individual surgeon competency. Most quality assurance tools have been punitive to surgeons, punishing those who perform poorly but not rewarding excellence with more than a stamp or a logo to put next to a practice name.

The Gyn network of surgeons is selected by peer review, and those who do not qualify are offered mentorship tracks to work with network physicians in order to advance training and eventually qualify for the network, or to work with network docs in order to facilitate cost savings and higher quality. This results in an INCLUSIVE culture, where surgeons can feel a sense of community with fellow surgeons willing and able to help advance the quality of care.

Surgeons can now apply to become part of a national NARROW NETWORK of qualified surgeons. Qualifying based on case volume, outcomes, and observation of unedited surgical videos leads to selected surgeons with increased patient referrals and better compensation through bundled payments. And the bigger the network, the better the offering to the self funded employers, the national health plans, and eventually CMS.

In order to free up the economic resources to pay our surgeons MORE per case, we had to investigate where the money was flowing. While many surgeons are aware of the opportunity to save on spending in the operating room via choosing one vendor’s equipment over another, we did not feel that mandating specific techniques or platforms would go over well with our colleagues. Surgeons don’t react well to being told exactly how, where, or when to perform a particular operation.

Instead, we focused on two major opportunities for savings. The first was by improving utilization of our outpatient options, including HOPD and ASC based cases. With lower overhead and highly efficient surgical teams, high volume surgeons could make a significant impact by embracing outpatient surgery, ERAS protocols for enhanced recovery after surgery, and same day discharge.

Beyond this was the opportunity to reduce complications and get patients back to work faster. By increasing the minimally invasive options and mitigating risk via shepherding patients to more experienced surgeons, the burden on the healthcare system would lessen.

This was proven first with an outpatient program at Portland’s Pearl Surgicenter, then was then expanded to markets in Atlanta, Dallas, Chicago, New York, and Minneapolis.

Soon, recipients of self insured companies were coming to Pearl Health Network surgeons and the results were exceptional. The agnostic nature of this network to focus entirely on one vertical has allowed for rapid growth within innovative payment models throughout the US for surgical services.

The secret sauce soon became the complex process of building BUNDLES. This Alternate Payment Methodology, which is part of CMS’s MACRA/MIPs value based healthcare system, became an obstacle. With many procedures and seemingly endless combinations of CPT codes, the number of case combinations to price was clearly impossible to solve using the current coding methods. In addition, it became imperative to provide cost comparisons for payers who were interested in savings and added value.

Pearl Health began taking risk for it network surgeons using a unique insurance product which allows complication protection for its bundled cases. This allowed the network to not only provide cost containment and expert care, but also would add a “warranty” on cases in the narrow network. The ability for payers to know with absolute certainty what the cost will be per case would be due to complication insurance and risk reduction was truly a unique product.

The economic impact of innovative disruption, working with medical device companies, hospitals, outpatient facilities, and payers, to truly deliver a better product in our vertical has paid off for Pearl Health and its strategic partners.

As Pearl Health scales its network from 6 to 30 cities, we are recruiting Gyn surgeons to pilot the unique bundles program.

Investment inquiries, surgeon applications, and general information can be sought at info@pearlhealthpartners.com

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