Healthy Worker 2020 Surgical Best Practices January 28, 2016

Shared understanding of individual components of “Surgical Cluster” Discussion about future direction of surgical best practices Objectives for Today

2005 Conduct Focus Group on Best Practices for Surgeons 2006 Begin Orthopedic and Neurological Surgeons Quality (ONSQP) Pilot 2010 Conduct Initial Evaluation of ONSQP 2011 Conduct Focus Group on Best Practices for Back Pain 2012 Complete Initial Design of Surgical Best Practices Pilot 2013 Begin Medical Provider Network 2014 Begin Surgical Best Practices Pilot 2014 Approve Lumbar Fusion Warranty and Bundle (BREE Collaborative) Evaluate and Integrate Components of Surgical Best Practices “Cluster” Surgical Best Practices Development Timeline

Presentation title Orthopedic and Neurological Surgeons Quality Project

Timely access to high quality surgical care to help injured workers rehabilitate promptly… HIGH QUALITY SURGICAL CARE TIMELY ACCESS … ensured by offering surgeons incentive pay for quality care. INCENTIVE PAY

Ortho/Neuro Project Development Process Implement quality and process improvement Recruit and train participants Develop incentive structure Recommend evidence-based quality indicators Conduct literature review

This potential best practice from the literature, recommended by the focus group for its likelihood to improve injured worker outcomes… …was translated into this quality indicator that a surgeon would be asked to demonstrate in the Ortho/Neuro Project: Providing an activity prescription for the injured workerComplete and Activity Prescription Form (APF) for at least 85% of injured workers: One APF at first office visit, and A second APF post-surgery. Provider directed intensive rehabilitation geared toward return to work On at least 85% of APFs, communicate worker’s rehabilitation plan that includes: Worker’s progress, and Current rehab plan. Minimal dispense as written (DAW) prescriptionsEndorse the evidence-based Washington State Preferred Drug List (PDL), and prescribe <10% DAW prescriptions (non-preferred drugs). Injured worker accessing specialist care within 7 business days of referral Timely access to service: For initial office visit appointments, 70% of injured workers seen by a specialist within 7 business days of referral (after the surgeon’s clinic has screened the referred patient). Non-emergency surgery completed within 3 weeks of surgical decision Timely surgery: Provide surgery within 21 days of claim manager authorization for 80% of surgeries subject to utilization review. Provider participation in occupational health continuing education Participate in 6 hours (or equivalent) of occupational health continuing education every two years.

How do surgeons earn incentive pay?

Provider Measurement Cycle Measurement cycle January 1 – June 30 July 1 – December 31 Tier reassigned November 1 May 1 Data analyzed Aug./Sept. Feb./Mar. L&I’s project team analyzes six months’ worth of data, then assigns each surgeon to their appropriate payment tier.

Current Ortho/Neuro Tier Status

Participant Survey (2009) Providers seeing as many or more injured workers. Requirements for tier achievement clear and reasonable. All quality indicators thought to have positive impact on injured worker outcomes except for minimal dispense as written and continuing education. Outcome Evaluation (2010) Providers made substantial progress in implementing the project. Providers who joined the program had better outcomes prior to the project compared to control group providers. No observable changes in duration of time-loss. However, UW explained the results could be due to immature pilot and premature evaluation. Findings from UW Evaluations

Presentation title Surgical Best Practices Pilot

Surgical Best Practices Pilot Development Process Implement pilot and begin process improvement Conduct RFP for pilot sites Analyze administrative data on surgeons/surgeries Group quality indicators by topic Recommend evidence-based quality indicators Conduct literature review

This potential best practice from the literature, recommended by the focus group for its likelihood to improve injured worker outcomes… …was translated into this expected behavior that a surgeon or surgical health services coordinator would be asked to demonstrate in the Surgical Best Practices Pilot: There is a documented pre-operative assessment of return to work (RTW) capacity and specific goals related to RTW post- operatively SHSC contacts injured worker and employer re: work options ₋Obtains job description Surgeon discusses return to work and recovery goals with patient ₋Happens post-op if surgery is emergent/urgent SHSC tracks activity in OHMS There is an integrated post-operative team (for example, COHE- delivered care) that will evaluate the patient if RTW goals are not met by 8 weeks post-operatively (or 12 weeks for lumbar fusion surgeries) SHSC and surgeon monitor progress related to return to work and recovery goals If patient progress is slow, case conference held with appropriate providers SHSC tracks completion of plan(s) developed during case conference The Surgical Coordinator assists in transitioning the patient back to primary care after surgery, when requested by the surgeon. SHSC forwards diagnostics, reports, job descriptions to AP, or Assists IW finding a new AP The SHSC assists in care transition when the primary care provider has referred patient for a surgical consult (requested by Ortho/Neuro project participants) SHSC contacts the AP and/or the IW to discuss transition to surgical care Collects medical records, diagnostics, reports for surgeon Documents and shares red or yellow flags with surgeon

15 Surgical Best Practices Pilot Sites

Role of the Surgical Health Services Coordinator (SHSC)

Standardizing SHSC Work

Launch Occupational Health Management System (OHMS) Identify or hire and train pilot staff (SHSC/Med Dir) Enroll providers at each site Incorporate SHSC into clinic processes Develop SHSC standard work Clarify roles of SHSC and COHE HSC Accomplishments in Initial Year

Develop reports using OHMS data Create tools to provide feedback to pilot sites and participating surgeons Determine appropriate SHSC case load (in process) Finalize process measures and benchmarks and/or thresholds Upcoming Work

Presentation title Warranty and Bundle

Bree Collaborative Established in 2011 “to provide a mechanism through which public and private health care stakeholders can work together to improve quality, health outcomes, and cost effectiveness of care in Washington State” Identify 3 topics annually where there is substantial variation in practice patterns and/or high utilization trends that do not produce better care outcomes. Bree Website:

Surgical Best Practices Pilot Development Process Gain approval by BREE Collaborative Post report for public comment Recommend quality improvement strategies in draft report Identify evidence-based best practice approaches using data Form expert workgroup

Lumbar Fusion Bundle and Warranty Lumbar fusion: High cost High complication rate May not benefit patients as much as other types of care Goal of Bundle and Warranty: Patient safety—highest priority Align payment with quality One payment for entire health care service Expected to have a lower total cost Coordination between health care providers, hospitals, and others Appropriateness Criteria (Pre-Op) BundleWarrantyQuality Outcomes

Lumbar Fusion - Warranty Warranty: A contract between provider and purchaser/payer where…provider will correct failure of their product…At no additional cost to purchaser 7 days a.Acute myocardial infarction b.Pneumonia c.Sepsis 30 days a.Death b.Surgical site bleeding c.Wound infection d.Pulmonary embolism 90 days a.Mechanical complications related to surgical procedure b.Deep wound infection involving hardware Appropriateness Criteria (Pre-Op) BundleWarrantyQuality Outcomes

Lumbar Fusion: Bundle Elements BUNDLE – Four Components 1.Document disability due to spinal abnormality despite conservative therapy 2.Ensure fitness for surgery 3.Provide all elements of high quality surgery 4.Facilitate rapid return to function And transparent quality metrics Appropriateness Criteria (Pre-Op) BundleWarrantyQuality Outcomes

Quality Outcomes – Five Categories 1.Appropriateness 2.Evidence-based surgery 3.Rapid and durable return to function 4.Patient care experience 5.Patient safety and affordability Lumbar Fusion: Bundle Quality Metrics Appropriateness Criteria (Pre-Op) BundleWarrantyQuality Outcomes

2014: Approve Warranty and Bundle - BREE Collaborative 2015 (December): Issue Request for Proposals - Health Care Authority 2016: Monitor Progress of Request for Proposals – L&I 2016: Investigate Use of Warranty and Bundle for Injured Workers – L&I Warranty and Bundle Status-Lumbar Fusion

Integration of Surgical Best Practices

Consistency within “Cluster”: Our goal is to integrate best practices for surgical providers into one program. Any concerns, considerations, or questions? Thoughts on how we might get there considering different stages of projects? What trade-offs might we need to make? Consistency across “Clusters”: How do we develop a well-integrated system of care for injured workers? Should opioid best practices replace the DAW quality indicator? What should be consistent and what should be flexible? Consistency across Payers: Is it more important to have consistency across state payers or to have programs tailored to workers’ compensation? What are the trade-offs providers and/or L&I might need to make? Discussion Topics