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Specialist Health Reform Survival Tips

I was asked by a good friend who is an orthopedic surgeon to put together a list of action items that a forward-thinking orthopedic surgery group should be considering during these dynamic health care times. From my former experience running a successful orthopedic practice and my current work with CIVHC focusing on health care reform specific to paying for high-value health care, I have assembled a list of suggested “to-dos” that specialists should consider to remain vital in the upcoming years.

  1. Gather your data. Health care is entering a performance-based world. Any practitioner should be looking at their own data, both claims and clinical outcomes.
  2. Evaluate your costs compared to your peers. Determine if you are practicing in a way that is more expensive than others in your specialty. If you are more expensive, use the data to determine why.
  3. Benchmark your performance. Utilize outcome measures wherever possible to gauge internal performance and benchmark your performance measures to national standards.
  4. Follow best practice standards. Determine what the best practice standards are for quality, cost and outcomes for the services you most frequently provide.
  5. Understand the quality and cost structure of your service partners. This includes understanding costs for hospitals, Ambulatory Surgery Centers, therapy, Durable Medical Equipment, etc. Identify which of your service partners are adding costs to the overall care being provided to your patients. Where possible, analyze quality metrics including patient satisfaction surveys for your service partners.
  6. Engage Primary Care Providers (PCPs) to assist them with improving cost and outcome measures. Many PCPs are starting to look for specialists to refer patients to that are focused on cost and quality. If you’re an orthopedic group, you might engage with a PCP group by saying something like, “We’d like to work with you to figure out how to provide better care at a lower price for your patients.” For PCP’s entering into Accountable Care Organizations (ACOs) that assume risk or have gain share opportunities, identify how you can partner with them. Every dollar you save them by decreasing complications and not performing unnecessary surgery is a dollar added to their bottom line which makes you a more attractive referral source.
  7. Consider taking a sub capitation contract with an ACO or large PCP group who is in a risk contract. This entails agreeing to a fixed payment each month to agree to care for a distinct patient population. Cardiology groups are already doing this in Colorado with several PCP groups along the front-range. To be effective, the contract must include guidelines to prevent “dumping” of patients on specialty group. Guidelines should also include care plans for conservative patient management handled by PCP’s and gain sharing opportunities for specialists.
  8. Differentiate yourself from your peers. Clear market differentiation will begin to occur with specialist groups that are willing to accept risk and work collaboratively with PCP’s to provide higher value care for patients. This requires data, physician leadership and governance. This is a big step and requires a sophisticated specialist group to operationalize and execute.
  9. Take steps towards global capitated payments. Intermediate steps should be taken before entering into a capitated, risk bearing contract. Gainshare with no downside risk is a good first step, and then you can incrementally add risk one procedure at a time as you gain expertise in managing care and better understanding the clinical and financial issues.
  10. Engage patients in making informed decisions. Consider implementing a formal shared decision making tool to ensure patients are engaged and informed about their health care choices and the costs associated with their decisions. Engaged Benefit Design in Colorado is an example of an organization dedicated to the expanded use of shared decision making tools. Learn more about their tools and resources at
  11. Eliminate unnecessary procedures. Specialists should understand where overutilization of services occurs within their field and take steps to reduce or eliminate unnecessary procedures within their practice. Failing to do this may put you or your practice at risk of payers eliminating payments for certain procedures and for being identified as a high utilization practice. Using the All Payer Claims Database data can provide a practice with their relative market performance, and resources like Choosing Wisely can help you identify overutilized procedures.
  12. Engage payers directly for data and ask for as much detailed data as they can provide. Understand what measures the payers are using to rate your group for cost and quality and let the payer know that you want to improve your performance but need data to assist with the evaluation. This will lead to establishing a more favorable position with the payer and to increased referrals and/or better contracts.

To be successful in health care in the future, all providers – specialists, primary care clinicians, hospitals, and other facilities – must start engaging in activities that demonstrate the value they can provide to patients and their health care partners. Now is the time to start focusing on your performance to be prepared for what health care reform brings your way. Please feel free to contact me at if you have questions or would like to discuss any of my suggestions in more detail.

About the Author: Bob Kershner is CIVHC's Director of Health System Payment Strategies. Contact him at

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