“Value based payment incentivizes health systems and provider groups to develop interventions that reduce clinical waste and overutilization,” stated Dr. Douglas G. Cave, President/CEO of Cave Consulting Group, Inc. (CCGroup). He continued, “A procedure with the greatest potential for clinical waste and overutilization is knee/hip replacements.”

For example, health services research implies that fewer than half of total knee replacements are appropriate. Moreover, up to 1% of knee/hip replacements result in an immediate (within 7 days) major complication such as blood clots, heart attacks, hemorrhage, and infections. At least 10% have a major complication within 6 months. “No wonder knee/hip replacements gain so much attention under value based payment,” stated Dr. Cave.

For these reasons, payers and health systems want to know the orthopedic surgeons that appropriately utilize knee/hip replacements and have good patient outcomes by US geographic region. Then, patients are directed towards these orthopedic surgeons. To make this strategy work, payers and health systems need a large claims database and advanced clinical analytics to accurately measure most specialists’ practice patterns.

Dr. Cave defined, “CCGroup maintains the largest database on orthopedic surgeon utilization and quality with respect to managing and treating prevalent medical conditions, such as degenerative joint disease (DJD).” This database is called the CCGroup-CMS Innovator Project. “We accurately and reliably measure the utilization and outcomes of over 80% of all practicing orthopedic surgeons in the United States,” stated Dr. Cave.

“We use the CCGroup Clinical Decision Support System to evaluate each orthopedic surgeon’s utilization and quality in performing knee/hip replacements in DJD patients,” mentioned Yuri Alexandrian, Chief Operating Officer of CCGroup. Medical condition MedMarkers™ and associated Clinical MedMarker Protocol Ranges™ are the foundation of the CCGroup Clinical Decision Support System.

MedMarkers™ are process of care quality measured, defined in clinical guidelines. However, MedMarkers™ also are key services most associated with cost of care in treating a medical condition. Clinical MedMarker Protocol Ranges™ are achievable and clinically appropriate ranges of clinical practice for a MedMarker™. These ‘Ranges’ are developed by presenting the CCGroup National Comparative MedMarker Database™ results to CCGroup National Specialist Panels.

Mr. Alexandrian explained, “Each orthopedic surgeon’s ranking is based on six (6) quality and utilization metrics in treating DJD of a specific severity-of-illness level. One of these metrics is knee/hip replacement MedMarker™ Complication Rate – an accepted outcomes measure.” The MedMarker™ Complication Rate is the percent of knee/hip replacements that resulted in a major complication in a post 7-day period.

“Nationally, the CCGroup-CMS Innovator Project shows the MedMarker™ Complication Rate for knee/hip replacement is 0.8% for DJD – mirroring other researchers’ results,” emphasized Dr. Cave. He continued, “However, the knee/hip replacement MedMarker™ Complication Rate varies significantly nationally between orthopedic surgeons – from 0% to over 10%.” The table below stratifies by complication class the 0.8% of knee/hip replacements with a major complication event.

The MedMarker™ Complication Rate varies significantly for other specialty types and medical conditions as well. Examples include the MedMarker™ Complication Rate for interventional cardiologists performing left heart catheterization and urologists performing cystourethroscopy.

About Cave Consulting Group, Inc. (CCGroup)

Cave Consulting Group, Inc. is a software and consulting firm located in San Mateo, California. The company is focused on improving the efficiency (cost-of-care) and effectiveness (quality-of-care) of the healthcare delivery system. Senior management of CCGroup has assessed the performance of physicians and hospitals for over 31 years for health plans, health systems, HMOs, physician groups, CINs, ACOs, TPAs, and employers.

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