Charting a Roadmap for Value-based Surgery in the Post-pandemic Era

Ten years ago, policymakers sought to renovate American healthcare by replacing its fee-for-service foundations with a valuebased care (VBC) framework, which seeks to maximize healthcare outcomes per unit cost of production. To promote this change, payers launched new care models which shifted accountability for outcomes and costs onto providers (ie, physicians and hospitals). However, although the first decade of VBC generated billions of dollars in savings, most progress has been an artifact of modifications to coding and referral practices rather than meaningful transformations to care delivery.1 Surgical care embodies the flaws in the current VBC movement. The fields natural inclination for outcomes measurement and access to technological cost levers make it well-suited for VBC. Yet, surgeons continue to be underrepresented in the design and deployment of VBC models such as accountable care organizations, which in turn have been unable to move the needle on surgical costs.2,3 Even for VBC initiatives targeting surgery such as bundled payments the changes in clinical practice have largely been downstream from surgical care (eg, post-Acute referrals).4 Given that surgical care accounts for roughly 30% of total healthcare expenditures and 50% of inpatient spending, there is a clear need for future VBC reforms that meaningfully engage surgeons, and their collaborators in anesthesiology and nursing, to reduce costs and improve outcomes.3 Adding to the impetus for change is the COVID-19 pandemic, which has exposed fundamental flaws in healthcares operating model. The resulting regulatory reforms for service modality (eg, telemedicine), site of delivery (eg, hospital at home), and organization of payment (eg, pressure for site neutrality) have long-reaching implications for both improving value within procedures and better integrating surgical care into the larger care continuum. In this article, we chart a roadmap for surgical leadership in the next decade of VBC. We argue that existing innovation in outcomes measurement and resource management coupled with the competitive pressures of COVID-19 create a unique window for value creation within surgical care.