Surgeon Quality Scoring - Sanjay Prasad - Episode 40

This video provides an in-depth exploration of surgeon quality scoring, patient empowerment in healthcare decisions, and the future role of technology, particularly AI, in optimizing surgical outcomes and costs. Dr. Sanjay Prasad, a neurotologist, head and neck cranial base surgeon, author of "Resetting Healthcare," and founder of SurgiQuality, discusses his mission to bring transparency to surgical care. He highlights the critical need for patients to make well-informed choices, challenging the current healthcare system where medical errors are the third leading cause of death and a significant percentage of surgeries are deemed unnecessary.

Dr. Prasad traces his journey from a passionate microsurgeon to an innovator in healthcare transparency. He recounts his early experience opening an ambulatory surgery center in 2007 to save costs by bundling services (surgeon, facility, anesthesia fees). This initial focus on price evolved into SurgiQuality, founded in 2014, with the crucial addition of quality metrics to bundled rates. His methodology involves granular, procedure-specific quality measures, such as bile duct injury rates for gallbladder surgery or adenoma detection rates (ADR) for colonoscopies, which are validated using a proprietary AI-powered engine that analyzes electronic medical records. This system allows surgeons to market their high outcomes and patients to choose providers based on proven success rates and lower complication risks.

The SurgiQuality platform targets self-insured employers, offering a concierge service that guides members through surgical decisions. When a member is told they need surgery, they sign a HIPAA release, and SurgiQuality's concierge collects medical records and imaging. This data is then sent to a network of surgeons who review the case, validate its necessity, and provide their past experience and outcome data. The AI engine scores these surgeons against peers and national norms, presenting the patient with a list of high-quality, cost-effective options within their network. This approach not only empowers patient choice but also aims to significantly reduce unnecessary surgeries—which Dr. Prasad estimates to be 15-30% across specialties, and as high as 80% for spine surgery—and mitigate stop-loss risk for employers by preventing catastrophic claims. He also envisions a future where digital technologies, wearables, and AI can predict health conditions and prevent major events like strokes or gallstones through early detection and lifestyle modifications.

Key Takeaways:

• Prevalence of Medical Errors and Unnecessary Surgeries: Medical errors are alarmingly the third leading cause of death in the United States. Furthermore, 15-30% of all surgeries are unnecessary, with some specialties like spine surgery seeing rates as high as 80%, leading to significant patient harm and healthcare waste.
• The Importance of Patient Pause and Inquiry: Patients should "pause" before scheduling surgery and ask critical questions such as: Is this surgery truly necessary? What are the alternative treatments? What would happen if I don't have surgery? What is the surgeon's success rate and complication rate for this specific procedure?
• SurgiQuality's Dual Focus: Cost and Quality: The platform combines bundled payment models with rigorous quality scoring to offer both predictable costs and superior outcomes. This evolved from an initial focus on cost savings through ambulatory surgery centers.
• Granular, Procedure-Specific Quality Metrics: SurgiQuality utilizes highly specific quality measures relevant to each procedure, such as the bile duct injury rate and conversion rate for gallbladder surgery, or the adenoma detection rate (ADR) for colonoscopies, to objectively assess surgeon performance.
• AI-Powered Data Validation: A proprietary AI-powered engine is used to validate surgeons' reported outcomes by analyzing their electronic medical records, ensuring the accuracy and reliability of the quality scores. This is a direct application of advanced analytics in healthcare.
• Empowering Patient Choice and Informed Decisions: The platform provides patients with intelligent, actionable information about surgeon quality and necessity, allowing them to make well-informed choices for their care within their existing network, thereby creating a "narrow network within a broad network."
• Concierge Service for Seamless Navigation: SurgiQuality offers a personalized concierge service that handles the administrative burden for patients, including sourcing medical records and imaging, and facilitating the peer-review process with surgeons.
• Benefits for Self-Insured Employers: By identifying high-quality, cost-effective surgical options and eliminating unnecessary procedures, SurgiQuality helps self-insured employers mitigate stop-loss risk and achieve substantial cost savings on healthcare expenditures.
• Incentivization for Members and Surgeons: While plan design dictates financial incentives for members, the core value is the quality-driven choice. For surgeons, participation offers an opportunity to reduce malpractice risk through peer-reviewed cases and attract patients based on their proven outcomes.
• Critique of Traditional Insurance Carrier Quality Vetting: Dr. Prasad argues that traditional insurance carriers often lack granular quality data on their network providers, focusing more on credentialing than on actual surgical outcomes. He highlights that carriers rarely inquire about specific complication rates or success rates from participating surgeons.
• Multi-Specialty Peer Review for Optimal Treatment: The platform facilitates multi-specialty opinions by connecting cases to various specialists, potentially leading to less invasive and more cost-effective treatments. An example given is a colon tumor being removed via a colonoscope by an interventional gastroenterologist instead of a major surgical resection.
• Rapid Turnaround for Critical Cases: The system can provide rapid turnaround for surgical case reviews, often overnight, as demonstrated by a case where a patient headed for craniotomy was found to have a viral lesion, preventing an unnecessary and costly procedure.
• Future of Healthcare: Digital and Predictive AI: The future of healthcare will be driven by digital technologies, the Internet of Things (IoT), and AI, enabling early detection of conditions (e.g., cardiac dysrhythmias, gallstones, Achilles tendon ruptures) and personalized lifestyle modifications, moving towards preventive care.
• Challenges to Healthcare Reform: While innovation flourishes in the private sector, challenges include overcoming the influence of powerful lobbies (e.g., the sugar industry impacting wellness initiatives) and convincing stakeholders of the value of transparent quality data.

Tools/Resources Mentioned:

• SurgiQuality Platform: A system for surgeon quality scoring, peer review, and bundled payments.
• "Resetting Healthcare" Book: Authored by Dr. Sanjay Prasad, a patient handbook for navigating post-COVID-19 healthcare.
• True Captive Insurance: A premier medical stop-loss captive for employer groups (podcast sponsor).
• Plansite: Technology for employee benefits brokers to manage RFP processes (podcast sponsor).
• Wearables (e.g., Apple Watch, Whoop, Oura Ring): Mentioned as future tools for health monitoring and early detection.

Key Concepts:

• Surgeon Quality Scoring: A system to evaluate and rank surgeons based on specific, granular outcome data for various procedures.
• Bundled Payments: A single payment for all services related to an entire episode of care (e.g., surgeon fee, facility fee, anesthesia fee).
• Adenoma Detection Rate (ADR): A quality metric for colonoscopies, measuring the rate at which a gastroenterologist finds a tumor, indicative of thoroughness.
• Self-Funded Health Plans: Employer-sponsored health plans where the employer directly assumes the financial risk for providing healthcare benefits to their employees, offering flexibility for innovative solutions.
• Stop-Loss Insurance: Insurance purchased by self-funded employers to protect against catastrophic claims that exceed a predetermined limit.
• Peer Review: The evaluation of work by one or more people with similar competencies as the producers of the work, used in SurgiQuality to validate surgical necessity and quality.
• Telehealth: The use of electronic information and telecommunications technologies to support long-distance clinical healthcare, patient and professional health education, and public health and health administration.
• Internet of Things (IoT): A network of physical objects embedded with sensors, software, and other technologies for the purpose of connecting and exchanging data with other devices and systems over the internet.
• AI-powered Engine: An artificial intelligence system used by SurgiQuality to analyze and validate surgeon data from electronic medical records.

Examples/Case Studies:

• Gallbladder Surgery: Discussion of specific quality measures like bile duct injury rate and conversion rate (necessity to open abdomen due to hemorrhage).
• Colonoscopy: Emphasis on the Adenoma Detection Rate (ADR) as a crucial quality metric to prevent missed tumors that could lead to liver metastasis.
• Spine Surgery: Dr. Prasad cites an orthopedic surgeon's claim that 80% of spine surgeries in Texas are unnecessary, often involving fusions that patients don't need.
• Brain Lesion Misdiagnosis: A patient with a seizure and a brain lesion on MRI was headed for craniotomy. SurgiQuality's peer review, conducted overnight, revealed it was a virus, not a tumor, preventing an unnecessary and expensive surgery.
• Colon Tumor Removal: A case where a patient scheduled for a major colon resection could instead have a cancerous polyp removed through a colonoscope by an interventional gastroenterologist, at a tenth of the cost and with faster recovery.