Mark Briesacher, MD: Hi, I'm Mark Briesacher. I'm the Chief Physician Executive at Intermountain Healthcare. Today I'm talking with Dr. Bob Hoesch, who is our Medical Director of the Neurosciences Clinical Program, and Dr. Stephen Warner, who is Medical Director for our Spine Development team.

I got to know Bob and Steve really well last year, when we started working on a project together focusing on making care safer and improving quality of care, and doing all that at the lowest appropriate cost in the neurosciences, and specifically in spine surgery. It is amazingly interesting, and it is a super important field of medicine for the people that we care for. It certainly was a pretty full and fun year last year, as we dove into that.

I think the question that I'd like to have you guys respond to, starting off the bat here, is I really get the sense that 2017 was a foundational building year for the Spine Development team, and the Neurosciences Clinical Program. Can you talk a little bit about that, especially in terms of what it means for our patients and families who are experiencing the medical conditions that are involved in spine care.

Steve, I don't know, why don't you start off with that.

Stephen Warner, MD: Well, I think last year, really, the primary success was actually the establishment of the NeuroPoint Alliance National Quality Outcome database. We actually have 17 physicians now, in the Intermountain system, that are actually collecting data on our patients, patient reported outcomes, to see how well they are actually functioning after we do these procedures on them.

I think that's a huge step forward. We can now combine the outcome data to all the other data that we've been collecting in the system for the past several years on complications, costs, length of stay, severity of illness. We can combine that, with actually, outcome data to see how they are functioning, how we improve their lives after these procedures.

Mark Briesacher, MD:

The actual surgical procedure is one part, a very important part of the complete management of a lot of spine conditions. Bob, I wonder if you could maybe share a little bit about how all that work fits into the broader parts of caring for people who have spinal conditions.

Bob Hoesch, MD: What we see is that the key to spine care, and especially spine care for painful spine disease, is to get upstream of the episode of illness, and to try to meet patients at the beginning of their episode, before their spine pain or back pain becomes chronic. Really a key for this is the establishment of a multi-disciplinary continuum for spine care. This is one of our goals for 2018, is to create this multi-disciplinary continuum, or multi-disciplinary centers for spine care in our major spine centers.

These centers include physical therapy, early in the process. That means quick access and easy access to physical therapy. It means coming up with programs where patients can pay for it easily, making it affordable for them. We've been working with our insurance carriers to come up with a bundle payment for physical therapy, for spine and back pain.

Other parts of the multi-disciplinary team include, psychological support, pain management, so that we're not prescribing more opiates, as a way to avoid surgery, and working with our phys-med and rehab colleagues on both interventional and non-interventional spine therapies.

Mark Briesacher, MD: It's remarkable how involved the surgeons are in this work and supporting these upstream interventions. Steve, what do you think are some of keys to bringing surgeons together to do all this?

Stephen Warner, MD: We started this Spine Development team five years ago and invited every surgeon in the Intermountain system to participate. That was one of the primary goals of the Spine Development team, was to get every physician that we could involved in this process, so that they had buy-in up front. They had the sense that their opinions and their comments were being heard and listened to.

Over the years, it's actually developed into the spine surgeons, we invite administrators from Intermountain Healthcare. You know, you've attended the meetings, it's that collaborative effort that really drives improving healthcare, and helping to maintain some of the costs that are escalating, all the new devices, the expensive...These procedures are so great, that we have to do something to drive that value so it's affordable to patients, and to the healthcare systems.

I think getting everybody involved, and it's been very nice in this Spine Development team, that we bring up issues about supply/cost. We bring up contracting of implants, or contracting of bone graft materials. We've had the support and participation of a large number of the surgeons within the system, which is really nice.

Mark Briesacher, MD: Having been in those meetings, what I appreciate is the frank and direct open discussion, and what...I especially appreciate the way that you lead that meeting in fostering that conversation.

Again, it's the remarkable thing to me here, the fact that you are looking at this holistically. What is the way that we can provide the safest, highest quality, most appropriate care at the lowest cost, so that we're delivering the right interventions, the right procedures, the right therapies, at the right time, in the management of these conditions, with the idea of moving as far upstream as possible to intervene early and effectively.

Steve, I'd like to come back to you, something you mentioned earlier around the Development team, and how you're now reporting to the National Database. I know you're also using our own internal data as well. I wonder if you could talk a little bit about how you and the Neurosciences Clinical program are using clinical data at Intermountain Healthcare to improve how we deliver care.

Stephen Warner, MD: We have what's called the Spine Dashboard. It's a collection of all sorts of parameters around spine care. It includes surgical volumes, time in the OR, length of stay in the hospital, costs of that care, complications such as DVT or pulmonary emboli, infections, etc.

We have this dashboard with all these parameters on our patients. We finally have started to get the data back, well established in specific cohorts, such as a single level lumbar fusion. Now we have that data on each and every surgeon, each and every facility across the system, so we can start to look at each one of these values across the system.

What we saw is a huge variation in the supply costs in the OR, from $4,000 up to $12,000. We then started to have discussions as a Spine Development team among the surgeons about what we were doing differently.

What we found is that, the primary driver of that cost variation were inter-body cages and bone graft materials. Last year we took on bone graft materials. We started to look at usage. We started to look at costs.

We got all the surgeons in the Spine Development team involved in that process. We renegotiated contracts with vendors. We were able to drive down the cost of some of these very expensive bone graft extenders.

Now we're starting to take a personal look. Each and every surgeon is starting to look at the cost, and whether or not it provides value to the patients that we're taking care of. We're having these open discussions now amongst surgeons. We can shape that care and drive down the costs without affecting the value to that patient.

Mark Briesacher, MD: It strikes me how similar this story is to the one that Dr. Brent James tells about prostatectomy. This goes back now almost 20 years. That group of urologists who got together at LDS Hospital to look at the very same types of data that you just described. This really became an early story of success, of a win for our patients. They were getting better care, and also for surgeons working together to improve how any given procedure is actually performed. It's remarkable the echo that I'm hearing across the decades here.

Do you have...Maybe even share a specific story or example of how the data helped a surgeon make a different decision about how they do a single level lumbar fusion?

Stephen Warner, MD: Sure. I think probably the best example of that is a material called cellular allograft material. It's very expensive. There's no evidence to support its use. We saw that it was being used across the system, and had a discussion. We pulled evidence-based literature, none of which actually existed. We had this discussion in the Spine Development team. Tracking the numbers now, we've actually seen a marked decrease in the use of these cellular based allografts that have no evidence to support their use.

It has markedly decreased the cost for some of the surgeons in the system, for performing these procedures.

Mark Briesacher, MD: Go ahead Bob.

Bob Hoesch, MD: One of the things I've really enjoyed seeing is the evolution of the Spine Development team. For the first four years, it was really focused on ... It was a stewardship team, focusing on cost per case, and utilization. Since the implementation of this Dashboard, and starting to use the Quality and Outcomes database, which is that nationally benchmarked database from the NeuroPoint Alliance, the Spine Development team has started to transition from just a stewardship team to a team that focuses on safety, quality, patient experience, and stewardship.

The other really important thing that comes out of this dashboard is important markers for each of the physicians about safety. Steve has been able to look at infection rates and has really interesting data about infections and surgeries. In addition to that, all the other hospital related safety indicators that we're following, we're able to match that up with surgical cases, PEs, and all the other safety indicators. This is really a huge step forward for the Spine Development team.

Mark Briesacher, MD: All right. I completely, completely agree. What's especially impressive is how this National Database also brings in the patient's voice, to help us know, are these things making a difference. You have surgeons and physical therapists, and rehabilitation docs, and patients all contributing to the information to help us then make better and better decisions about spine care.

It's truly amazing.

Bob Hoesch, MD: When we started with the database, I thought of it as the quality outcomes database. It's quality, it's what we use. It's our best quality indicator, how our patient's doing neurologically, three months and one year later. That's the most important thing. Can they walk? Can they return to work? Are they on opiates? What's their pain scale rate?

I just thought about it recently when the Office for Patient Experience was established. I was like, this is actually patient experience.

Mark Briesacher, MD: Mm-hmm. Yes, yes.

Bob Hoesch, MD: The patients are telling us how they're doing.

Mark Briesacher, MD: Yes.

Bob Hoesch, MD: What more important indicator can we have?

Mark Briesacher, MD: You're exactly right.

Stephen Warner, MD: That's our critical case, because as we make changes, we want to make sure that it doesn't affect that patient experience and quality improvement. I think that's the key piece. You've got to have to tie the two together. We can't make these big changes without knowing how it affects the outcome for our patients.

Mark Briesacher, MD: Being in a position to do that with the physicians and surgeons all working together as a group, with the Spine Development team, I think, it's just the best type of environment to make those types of decisions.

Stephen Warner, MD: I think that's key. As we move forward, the goal is to involve other disciplines, the physical medicine rehabilitation physicians, the physical therapists, because then you have a conversation among the spine care professionals. Everybody has some input. They have experience. They have education from a meeting that they went to. Everybody has a different experience that contributes to the improvement in that care of that patient.

Who best to actually review it and look at it, is the physicians that're involved in those patients' care. That's what we're currently doing. We're having those discussions now with the Spine Development team. What is the best way to perform an uncomplicated single level lumbar fusion for our patients? What are the indications for an inner-body cage. What are the indications for bone morphogenic protein, if there is an indication, and developing that best practice that you talked about, Brent James, and the ATP Program. That's the goal, is to come up with these best practice outlines for physicians.

Mark Briesacher, MD: Well Bob and Steve, thank you so much for meeting today, and for the great conversation. I have no doubts that what you are building is the best comprehensive spine program in the state, and across the country. I know that it's very reassuring to me, as a primary care physician, to know that I've got great colleagues to refer our patients to, to get the best care possible. I know that means a lot to all of our family medicine and internal medicine docs out there who are on the front lines taking care of people in Utah and southern Idaho.

Thank you very much.

Bob Hoesch, MD: Thanks, Mark.

Stephen Warner, MD: Thank you very much, Mark.