Closing In on Healthcare’s ‘End Result’

Ernest A. Codman, M.D., never really fancied himself a visionary. An intense, uncompromising figure with a charming whimsical streak and a strong devotion to his professional beliefs, Codman once described himself as “quixotic” or a “little queer.” 

That depiction, however, was likely an aberration. Throughout his life and particularly during his fight for medical reform in the early 1900s, Codman admitted only to dogged determination, belligerence, and sincerity. In fact, he considered ideas like physician accountability and transparency to be quite sensible, as together, they could potentially raise standards, reduce healthcare costs, boost patient choice, and bolster learning.

Codman began practicing medicine in 1895 and led a rather ordinary professional life until the turn of the 20th century, when he began pressing doctors and hospitals for treatment outcome studies. He boldly championed the notion of “end results,” urging his colleagues to provide follow-up patient exams one year after surgery or discharge from a hospital to determine overall treatment efficacy. Codman also wanted hospitals to standardize and publish the data to give patients better access to quality care and physicians better insight into the best treatment options.

Codman explained his “end results” idea quite simply: “The common sense is that every hospital should follow every patient it treats, long enough to determine whether or not the treatment has been successful, and then to inquire, ‘If not, why not?’ with a view to preventing similar failures in the future.”

A noble concept, undoubtedly, though it was a wildly unpopular one as well. Backlash from the medical community eventually prompted Codman to open his own 12-bed “end results hospital” in a Boston, Mass., brownstone in 1911. The orthopedic surgeon compiled his own personal “end results card” over the next five years, tabulating the outcomes for each of the 337 patients discharged from his tiny institution during that time. Codman recorded 123 total errors, most of which were caused by lack of knowledge or skill, surgical judgment, lack of care/equipment, or lack of diagnostic skill. Four of the mistakes were “calamities of surgery or those accidents and complications over which we have no known control.”

Codman’s comrades, of course, assailed his attempt at medical reform, with some even deeming it heretical. Despite the backlash, however, Codman continued to fight for transparency and accountability in healthcare, predicting that “… the end result idea may not achieve its entire fulfillment for several generations…”

Or longer. While four generations have passed since Codman’s very public ostracizing by colleagues (three since his death in 1940), the medical industry is only now truly warming to the concept of linking care, errors, and end results to improve the overall quality of healthcare. The Patient Protection and Affordable Care Act of 2010, for example, created several new Medicare programs that base reimbursement on provider performance, including adherence to certain care processes, patient satisfaction scores, and treatment outcomes.

Predicated, essentially, on end results.

One of those programs began in April. The Centers for Medicare & Medicaid Services (CMS) revamped its payment model for hip and knee replacements by tying payments (or penalties) to patients’ overall recoveries. The move is part of an extensive effort by the U.S. government and health insurers to establish value-based healthcare.

The Comprehensive Care for Joint Replacement (CJR) model puts hospitals in 67 metropolitan statistical areas in charge of ensuring cost-effective surgery and patient recovery for 90 days after hospital discharge. The program is being phased in gradually, with no financial penalties for first-year underperformers. The worst offenders thereafter will be required to repay up to 5 percent of their patient reimbursement in the second year, 10 percent in the third year, and 20 percent in the fourth and fifth years. Bonus reimbursements for top performers will follow a similar path.

“The CJR model creates incentives that encourage collaboration among hospitals, physicians and other clinicians, and post-acute care providers…” CMS Chief Medical Officer Patrick Conway, M.D., wrote in a blog post last fall.

The model also is inspiring collaboration among orthopedic device manufacturers. Just weeks before the program was implemented, DePuy Synthes announced an exclusive strategic alliance with Value Stream Partners, a company specializing in hip and knee replacement bundled payment program development and implementation.

And several weeks after the CJR rollout, Stryker Corp. launched an Internet-based program for hip and knee replacement patients. The platform is available through Stryker’s Destination Centers of Superior Performance offering, which includes more than 270 U.S. hospitals with care redesign programs for total joint replacement patients.

Stryker’s JointCOACH program is a web-based communication platform that enables joint replacement patients to communicate by computer or smart phone with their hospital care team during the entire episode of care (from the time of surgery to 90 days post-discharge). Pre-op preparation, clinical protocols, medication data, recovery, and rehabilitation activities are delivered at key time intervals to patients during their journey, with a series of questionnaires and surveys to help ensure they are involved and engaged in their care plan, and experience a successful recovery.

“With this new platform,” Vice President and Reconstructive Division General Manager Stuart Simpson said, “we have created a continuum of patient service that results in optimal care and positive outcomes.”

Just like Codman envisioned.