Hello, Relentless Tribe. Thank you so much for showing up today. All right … to start, let me lay out the goal of the episode today. This episode is for you if you are a self-funded employer looking to ensure your members are steered and tiered to real high-value care and/or if you are a clinical leader looking to show up in the real high-value care tier and/or deliver at the highest possible value to the community. Yeah, if you fit any of those descriptions, please stay tuned.
For a full transcript of this episode, click here.
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I, for one, left this conversation pretty darn, I don't know, hopeful is maybe the right word. My guest today is Dr. Ahilan Sivaganesan—otherwise known as Dr. Siva—and we are discussing … I'm gonna call it the death of the "what is value" guessing game, because today we're digging into what Dr. Siva calls the Operative Value Index, the OVI.
The OVI is a common mathematical language that allows purchasers to finally have the math to move away from some very lazy status quo provider networks where value, cost, and quality is highly variable across network providers. Let's just leave it at that.
The OVI reminded me of an article that Dana Prommel Strauss had written about and quoted some weeks ago where she talked about what is the health dividend that results from delivered care. So, these ideas (it sounds like) are ideas whose time has come.
Okay … so, on the pod today, Dr. Siva shows how to identify using the OVI, the rock star surgeons and/or other clinicians who deliver care that is the highest value for their patients. He uses these bubble charts that you can check out if you are interested. Just go back later on and check 'em out.
And this whole endeavor—let's just not lose track of this—has obvious implications for provider organizations. But for anyone who is paying for care and has an actual aligned incentive to ensure that the care is high value, this OVI (Operative Value Index) and its common math also allows us to pay in a way that, just saying the quiet part out loud, we can pay in a way that isn't one big old outta-the-gate perverse incentive.
Which, you know, we can say a lot about a lot; but if we're talking FFS (fee for service) or even most bundled payments at their just basic fundamental level, the only way the surgeon gets paid is to do the surgery, as just one example.
If you're looking to align everyone around the common goal to have the best outcomes for the patient, that doesn't cut it. Weird pun not intended at all, but yeah.
Dr. Siva says, coming up here, he says, "You don't have to just do [the math, the bubble charts] at the procedural level. You can [do them] at the diagnosis level … which I think is even more interesting to a self-funded employer [or] a payer. Because if I'm a surgeon that is appropriately conservative, I don't just cut on everyone. I'll send that patient to PT if I really think that's the highest-value next step. …
"And let's say my patients do really well with that conservative approach. I'm gonna look like a rock star on these bubble charts because I'm going to be getting great patient-reported outcomes, and my spend is gonna be a lot less 'cause I'm not doing surgery on everybody.
"And so finally, there's a way for me to be rewarded in a way that the metrics are designed compared to someone who's just doing surgery on everyone. … We haven't had the language or the framework to be able to actually compare surgeons or practices on value that incorporates appropriateness or conservatism in the right way."
I found that really interesting, and it also reminded me actually of the episode (EP434) with Ben Schwartz, MD, MBA, about five surprises with bundled payments, because Dr. Schwartz also talks about the idea of diagnosis-level bundles.
Okay … so, let me take a dip back now from whence this episode came—its genesis, if you will.
This whole thing started out (for me, at least) with the revelation of an episode with Mick Connors, MD (EP495), where I first cottoned on to this idea that our typical value definitions are based on a mix and match gone awry. I mean, we all say value equals outcomes divided by cost. And we say this very confidently.
But let's get real. Across most of this $5.6 trillion sector, both of those numbers—outcomes and cost—are total question marks. It's weird, though. It's a weird thing because we tend to roll up costs, roll 'em up in a vaguely cryptic and inarguably triangulated way, and then we break down outcomes to the level of, like, a blood test.
We should flip that. Get those costs defined as close as we can to the unit or to the unit and roll up the outcomes to whole-person care. Definitely go back and listen to the episode with Dr. Mick Connors. There's also an episode on whole-person health with Scott Conard, MD (EP462), which could be a nice round-out here. Alex Sommers, MD, ABEM, DipABLM, wrote some posts on or about this recently.
And this is the point Dr. Siva made in the quote I read earlier, and you will hear this again in the episode that follows. You can't figure out who or where the high-value care actually is unless you figure out the actual value.
And to figure out the actual value, you need to figure out the quantified outcomes and the unit level costs. Mark Cuban wrote on LinkedIn on this topic with over 900 comments. So, hitting a chord here.
Today, as aforementioned, my guest is Dr. Ahilan Sivaganesan, Dr. Siva. He is a practicing neurosurgeon at Mishe Health (Head of Quality and Value) and also a national leader in value-based care. His research focuses on the costs and outcomes of spine surgery. He also writes and speaks about redesigning care models, mapping patient journeys, and eliminating waste in healthcare.
By the way, at the very end of this conversation, we get to the why, as in why it is becoming increasingly an imperative for clinical organizations to figure out how to get past the inarguable complexities—and it is difficult; no one's arguing with that—get past all of that. Also get past the weird little stack of perverse incentives to not accurately calculate costs and outcomes. Really get to actually doing it.
As Dr. Siva says—and he wrote a whole article about this—but he says near the end of this conversation how Yahoo laughed at the little upstart Google for not understanding that the business model here was keeping eyes on a home page and putting ads on the home page. Yahoo laughed and disparaged … until they didn't.
Dr. Siva talks about how we're coming up on a similar kind of Google moment. It's just maximizing fee for service is Yahoo, and being able to actually deliver quantitatively high value is Google.
This episode is sponsored by Aventria Health Group, and we had an assist from Payerset. Payerset has price transparency data in a very elegant interface. You can use it to turn negotiations into partnerships. Certainly check them out. And I thank Payerset so much for offering financial support to keep this podcast on the air. Thank you very much, Payerset.
Okay … so, let's get to my conversation with Dr. Ahilan Sivaganesan.
Also mentioned in this episode are Hospital for Special Surgery; Mishe Health; Dana Prommel Strauss; Benjamin Schwartz, MD, MBA; Mick Connors, MD; Scott Conard, MD; Alex Sommers, MD, ABEM, DipABLM; Mark Cuban; Aventria Health Group; Payerset; Rishi Wadhera, MD, MPP; Rebecca Etz, PhD; The Larry A. Green Center; Marty Makary, MD, MPH; Ryan Wells; Adam Stavisky; Leo Spector, MD, MBA; Ivana Krajcinovic, PhD; Jacob Asher, MD; John Lee, MD; Sam Flanders, MD; and Kada Health.
For a list of healthcare industry acronyms and terms that may be unfamiliar to you, click here.
You can learn more by following Dr. Siva on LinkedIn.
Ahilan Sivaganesan, MD (he goes by Siva or Dr. Siva) is a practicing neurosurgeon with the Hospital for Special Surgery in Naples, Florida, and is the Head of Quality and Value at Mishe Health. Clinically, he is an expert in minimally invasive and endoscopic spinal procedures. He also directs a research lab dedicated to value-based care.
00:00 Introduction to this episode.
00:38 The goal of this episode.
01:28 What the Operative Value Index (OVI) is.
02:04 A quick episode overview.
04:23 EP434 with Benjamin Schwartz, MD, MBA.
04:44 How this episode came about.
09:24 How Dr. Siva got involved in the research around outcomes and costs.
11:51 How the value equation doesn't add up to true quality.
14:12 What measuring quality across the entire care journey means.
15:00 EP326 with Rishi Wadhera, MD, MPP.
15:08 EP295 with Rebecca Etz, PhD.
16:07 Why appropriateness is the foundation of quality.
19:08 Why practicing clinicians need to be thinking about the true costs of delivering care.
21:20 Time-driven activity-based costing (TDABC).
23:44 The two things that must be known for value-based care to succeed.
24:06 Article by Dana Prommel Strauss.
27:09 A quick summary of the conversation thus far.
30:42 The power of transparency in Dr. Siva's bubble plots.
32:39 EP449 with Marty Makary, MD, MPH.
34:05 Why these bubble plots work not just at the procedural level but at the diagnosis level, too.
36:13 EP503 with Ryan Wells; Leo Spector, MD, MBA; and Adam Stavisky.
36:21 EP501 with Ivana Krajcinovic, PhD.
36:30 EP398 with Jacob Asher, MD.
37:28 The "big blue ocean" opportunity for forward-looking providers.
38:52 Substack post by John Lee, MD.
40:37 The incredible opportunity for entities and groups that can help provide the infrastructure needed for this value index.
41:42 Essay written by Dr. Siva.
43:19 Last thoughts by Dr. Siva on TDABC and competition on value.
Recent past interviews:
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Ryan Jacobs; Stacey Richter (INBW46); Ryan Wells, Dr Leo Spector, and Adam Stavisky; Brian Machut; Ivana Krajcinovic; Dr Jacob Asher (Take Two: EP398); Stacey Richter (EP500); Dr Jay Kimmel