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For PPOs – Costs, Medical Policy, Network Management
Cost Benefit Issues
PPO executives have an interest in encouraging the appropriate use of minimally invasive procedures. For patients, use of less invasive procedures results in less pain, shorter hospitalization, and faster return to work. But, the cost equation is not entirely clear cut. The cost benefit outcome depends in part on efficient use of surgical time, equipment, and facilities. Many of these cost drivers can be monitored and negotiated by PPOs.
While clinically effective, laparoscopic procedures can take more time in the operating room, meaning that operating time must become a quality metric for hospitals, surgeons, and PPOs. The EVALUATE Study in Australia found that not all procedures were equally cost effective, but noted that surgical decisions regarding use of disposable or reusable equipment had an impact on reported costs. The surgical landscape is changing for hysterectomy; PPOs need to monitor and negotiate for cost effective rates from hospitals and also demand quality metrics on clinical and patient quality of life outcomes.
Costs vary considerably over time, and changes in surgical procedure techniques and experience of surgeons changes the cost and complication profiles of procedures. This is perhaps why there are also studies showing that MIP can cost less than open procedures when the total cost of hospitalization is considered. The articles identified below discuss some of the cost and quality considerations relevant to hysterectomy:
Medical Policy
PPOs have the potential to use medical policy and medical management programs to encourage network physicians to adopt clinically recommended less invasive approaches to hysterectomy. A shift to less invasive approaches could have quality benefits for patients and cost benefits for customers.
PPO medical policy on hysterectomy primarily addresses issues of medical necessity for hysterectomy, and the medical appropriateness of routes of surgery for various clinical indications. Medical policies tend to take a non-directive approach to the route of hysterectomy, although several cite specialty society guidelines such as ACOG that recommend vaginal and laparoscopic surgery above open abdominal.
PPOs could adopt a variety of approaches to promote a shift, ranging from:
- Require preauthorization of hysterectomy and review cases not requested for minimally invasive approaches;
- Require justification for surgeries not performed by MIP;
- Offer physician CME or other voluntary approaches to encourage evidence based referrals by PCPs and uptake of minimally invasive practices by surgeons;
- Offer shared decision making tools for members to enable them to review hysterectomy surgery options;
- Apply financial differentials for patients who choose an open hysterectomy when MIP is available in the network and clinically appropriate;
- Apply financial differentials to provider payment to either encourage MIP through enhanced pay or discourage open surgery through reduced reimbursement.
An example of medical policy for hysterectomy is linked below. Not all PPO policies are available on the web and some organizations appear not to have a medical policy specifically on hysterectomy.
CIGNA Medical Policy
Network Strategy
Information on MIP-trained physicians could be provided to members in the provider directory, physician locators services or member services. A PPO that makes physician information available to members may have better success at moving the market towards minimally invasive procedures – a service that will be of value to payers and employers.
However, information on physicians offering MIP is limited. PPOs do not yet have a readily available comprehensive method to identify practitioners offering minimally invasive procedures. PPOs will need to create the demand for certifications and other skills based indicators in order to increase availability and uptake of these programs.
Physicians trained in MIP can currently be identified through a number of different sources that can include:
- Self identification – physicians offering surgical services could be asked to provide information on capabilities and training to offer minimally invasive procedures.
- Hospital credentialing – hospitals can be asked to provide a roster of physicians performing minimally invasive procedures;
- Specialty societies – Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and the AAGL both offer certifications in laparoscopic or minimally invasive surgery and have web-based tools for identifying physicians:
PPOs can increase uptake of minimally invasive surgery by increasing availability of surgeons performing MIP in the network. Once capable providers are identified, strategies for increasing use of MIP providers in the network include:
- Improve referral patterns to increase volume of MIP procedures for providers trained with specified skills or procedures
- Educate members on availability of minimally invasive procedures for a variety of surgical interventions
- Advertise and promote hospitals or outpatient facilities that perform a majority of procedures minimally invasively and with exemplary quality metrics
- Provide decision support tools for member using the plan website for clinical information or referrals
- Talk with payer-customers about benefit incentives or differentials to promote less invasive surgeries
- Offer physician incentives for incremental performance improvement, which could including obtaining certification, performing the majority procedures using minimally techniques or for shifting practice patterns towards MIP.
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