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When Choosing a Hospital, Focus on Value Across the Total Episode of Care

There are many factors that may play a role in determining which hospital a patient chooses to go to for care – everything from location and reputation to recommendations from family and friends. As Chief Value Medical Officer at HSS, it may not be surprising to learn that I believe value is one of the most important factors to consider.

Value in healthcare can be loosely defined as the quality or outcomes of care divided by cost. At HSS, our approach to creating value for our patients is to provide the highest-quality care and best outcomes, but to do it in the most cost-effective way. We do this not just during the time a patient is physically in our care but also throughout the entire patient journey, from pre-admission to surgery to the return home – or, as we call it in my area of expertise, across the total episode of care.

What does it mean to choose a hospital that delivers high-value care? It’s a little like shopping in advance for a car that’s reliable versus buying one off the lot because it looks to be in decent condition. When researching a car, you may look up safety data, fuel efficiency or other factors. Similarly, there are questions you can ask hospitals to find out whether the care they provide is trustworthy.

The problem is most hospitals don’t make this information widely available, and too few patients have the information they need to ask for it in the first place. To help people make more informed decisions, we at HSS recently launched a new tool called the HSS Hospital Reliability Scorecard, which is designed to help anyone having surgery, no matter where they seek out care. The tool features five factors of reliability that indicate how consistent a hospital is at performing a given procedure. They include the following: (1) patient-reported success rate, or the percentage of patients who reported an improvement after the surgery; (2) patient experience, or the percentage of patients who would recommend the hospital, their rating on a five-star scale, and the number of patients providing recommendations; (3) rate of complications as compared to the national average; (4) number of avoidable hospital visits and the percentage of patients readmitted to the hospital within 90 days compared to the national rate; and (5) total procedure volume, or the number of surgeries the hospital performs annually and how that compares to the next leading hospital.

The five factors identified above were developed based on feedback from patients regarding the things that matter most to them when deciding where to have surgery. Patients considering a procedure should ask hospitals that they are considering about how they perform on these five factors and compare how the different hospitals perform.

Another factor not represented on the HSS Hospital Reliability Scorecard that I urge patients to consider is the anticipated cost of the entire episode of their care, including the cost of medical services they may require after surgery. Patients may pay extra for these services, not just in dollars and cents but also with their time. For example, rehabilitation is typically required after hip or knee replacement. This may involve accessing services from home or going to a skilled nursing facility or an inpatient rehabilitation facility. Patients with their doctors should carefully consider their health needs for post-surgical care and avoid unnecessary services, which can be very costly.

Being responsible stewards of healthcare spending as providers can not just benefit our individual patients but also gives us an opportunity to improve the quality of care we provide and reduce overall costs. In a study published in the October 2021 issue of NEJM Catalyst Innovations in Care Delivery, my HSS colleagues and I showed that by providing high-quality care efficiently, HSS reduced readmissions and utilization of unnecessary intensive rehabilitation after knee and hip replacements, and at the same time saved the Centers for Medicare & Medicaid Services (CMS) millions of dollars from 2014 to 2019. These results were from our assessment of HSS’s participation in CMS bundled payment programs, called the Bundled Payments for Care Improvement Initiative and the Comprehensive Care for Joint Replacement program.

Participation in these programs has also allowed HSS to use cost savings to develop new initiatives for improving quality across the entire episode of care. For example, we implemented a health optimization program to identify patients with 11 high-risk factors that lead to worse postsurgical outcomes, such as obesity, uncontrolled diabetes and malnutrition. As a result of this program, HSS surgeons recommend counseling and physical therapy before surgery to ensure patients are as fit as possible prior to their procedure. It’s initiatives like these that can help drive down complication and readmission rates even further, which is a result that truly benefits everyone.

  • Catherine MacLean, MD, PhD, Chief Value Medical Officer at the HSS Center for the Advancement of Value in Musculoskeletal Care