Western New York Health System Works with CCGroup to Prepare for CMS Ambulatory Specialty Model Payment – Part 1

SAN MATEO, Calif.--(BUSINESS WIRE)--“Our health system client resides in a region selected by CMS for mandatory specialist participation in treating Medicare beneficiaries with low back pain (LBP) and congestive heart failure (CHF),” stated Dr. Douglas G. Cave, President/CEO of Cave Consulting Group, Inc. (CCGroup). He continued, “The CMS Ambulatory Specialty Model (ASM) is designed to reward cost savings achieved by reducing unnecessary procedures and preventing avoidable hospital outpatient and inpatient utilization.”

CCGroup analyzed the health system’s LBP and CHF treatment profitability under CMS ASM payment. “We initially addressed the ‘unnecessary procedures’ component in treating LBP by the health system’s orthopedic and pain management specialists. To perform the evaluation, CCGroup used the CCGroup-CMS Innovator Project Database – the nation’s largest database on specialist utilization and quality with respect to managing and treating prevalent medical conditions,” said Dr. Cave.

Orthopedic Surgeons: Low Back Pain Results
Severity Level	Procedure of Interest	Region Median	Client Results
1	Intraspinal Injections	6%	5%
1	MRI Joint Extremities	1%	1%
1	MRI Spine	38%	50%
1	Spine/Vertebral Surgery	2%	3%
2	Intraspinal Injections	11%	17%
2	MRI Joint Extremities	1%	0%
2	MRI Spine	54%	66%
2	Spine/Vertebral Surgery	70%	66%
Pain Management: Low Back Pain Results
1	Destruction by Neurolytic Agent	6%	9%
1	Intraspinal Injections	28%	36%
1	Nerve Block	39%	30%
1	Neurostimulator	0%	0%
2	Destruction by Neurolytic Agent	27%	36%
2	Intraspinal Injections	28%	28%
2	Nerve Block	62%	59%
2	Neurostimulator	1%	0%

“Utilization results show that the health system has opportunity to improve performance on current LBP practice patterns,” asserted Yuri Alexandrian (COO/CIO of CCGroup). “Several improvement findings are the following (refer to table).”

• Orthopedists: LBP severity level 1 episodes (e.g., sprain/strain back) are treated for $1,700 per episode as compared to the regional median of $1,440 per episode. A reason for the higher client amount is that 50% of LBP severity level 1 episodes have an MRI spine as compared to the 38% regional median; and 66% of LBP severity level 2 episodes (e.g., spinal stenosis) have an MRI spine as compared to the 54% regional median.

• Pain management: LBP episodes of severity level 1 episodes are treated for $1,610 per episode as compared to the regional median of $1,390 per episode. A reason for the higher client amount is that 9% of LBP severity level 1 episodes have destruction by neurolytic agents as compared to the 6% regional median; and 36% of LBP severity level 2 episodes have destruction by neurolytic agent as compared to the 27% regional median.

“The health system’s current utilization and quality results place them at-risk for potential repayment of Medicare Part B payments for LBP treatment under ASM,” stated Dr. Cave. However, the health system now understands where to focus treatment improvement efforts.

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 33 years for health plans, health systems, HMOs, physician groups, CINs, ACOs, TPAs, and employers.