Source: Stryker Instance
Over the past decade, healthcare reform's focus on value-based healthcare and improved patient outcomes—combined with major advances in orthopeadic technologies—have had a significant impact on the economic and clinical aspects of orthopeadic practice.1,2 Orthopaedic surgeons in private practice, in particular, have been tasked with navigating a data-driven, value-based reimbursement environment, while at the same time, providing their patients with excellent care delivery.
Despite the trend toward the consolidation of physician practices into hospital systems, a 2016 survey conducted by the American Academy of Orthopaedic Surgeons (AAOS) found the most popular practice setting was private practice–group, 35% followed by academic practice, 19%, hospital/medical center, 17%, private practice–solo, 11%, and private practice–multispecialty, 9%.3 Locum tenens, military, health maintenance organizations, public institution, and other practice settings rounded out the remaining 9%.3 For many orthopaedists, the benefits of private practice outweigh the security afforded to hospital-employed surgeons, including autonomy, the ability to build loyal patient and referral relationships, as well as the potential financial upside of not working for an employer.4,5
However, to thrive within the current value-based landscape, private practice orthopaedists must be able to effectively juggle the administrative and business demands of running a practice, as well as deliver excellent care to their patients. Orthonomics, a concept that encompasses the interconnected goals of improving practice efficiencies, optimizing clinical and economic outcomes, and enhancing patient care through clinical and technological innovation, is a useful lens for examining how orthopaedic surgeons can achieve excellence in patient care and manage financially viable practices.
“We must transition from being just surgeons to becoming administrators,” says Andrew Wassef, MD, an orthopeadic surgeon at Long Beach Orthopedic Institute, an orthopedic surgery group located in Long Beach, CA, citing what he identifies as the need for “increased efficiencies in managing patients to survive in a more competitive marketplace.”
In addition to competition from hospitals and other PGPs, orthopaedic practices must deal with increasingly complex, value-based reimbursement systems. In 2017, changes to the 2015 Medicare Access and CHIP Reauthorization Act (MACRA), created a two-track Quality Payment Program that included the Merit-based Incentive Payment System (MIPS), a pay-for-performance model that rewards providers based on metrics for quality, resource use, clinical practice improvement activities and meaningful use of an electronic health record system.6,7
Providers who don’t meet the MIPS performance measures receive lower reimbursements or none at all. These payment models may lead orthopaedists to place greater emphasis on meeting electronic data capture and reporting mandates, delivering cost-effective, measurable patient outcomes, while still balancing the myriad business aspects of running a practice.7,8,9
“We need to be excellent to be viable,” says Yogesh Mittal, MD of The Orthopedic Center in Tulsa, Oklahoma, whose practice
comprises both an urban and rural patient population. He notes that, “good managers put on their business hats in order to bring best practices to the patient.” Dr. Mittal suggests that this may also mean, “taking advantage of other lines of business that may generate more revenue and be less costly to patients than hospital-based services such as MRI’s.”
From a practice-building perspective, the ability to provide excellent care is critical for PGPs, since quality patient care is a significant way PGPs can distinguish themselves from competing hospitals.5 “Our practice blossoms when patients recognize that our surgical care is good—we don’t just disappear after a procedure,” continues Dr. Mittal, referring to the personalized level of patient care a private practice can provide.
Both Dr. Mittal and Dr. Wassef point to opportunities for orthopaedic PGPs to take a leadership role in promoting excellence in surgical care, especially in optimizing quality and reducing costs in knee and hip arthroplasties. This means working with hospital systems to make available evidence-based care pathways and technologies that have the potential to enhance cost-effective, patient-centered care.
“By being more clinically integrated with hospital systems, we can define success for the orthopaedic community,” notes Dr. Wassef. He adds that this can include the financial savings related to better patient outcomes as well as leading the way in creating “community based centers of excellence.”
Numerous studies of the CMS Bundled Payment for Care Improvement (BPCI) and the 2015 Comprehensive Joint Replacement (CJR) model, that covers a 90-day episode of care, have shown that discharge to home, versus an in-hospital rehabilitation facility, was associated with reduced costs, fewer complications post-discharge, and lower rates of readmissions.10,11
Dr. Mittal and Dr. Wassef agreed with these findings by stressing their experience involving patient satisfaction and outcomes due to discharging patients to home, as well as the value of coordinating care with the hospital and other providers within the 90-day episode of care. “Understanding your role working with the hospital system can help give the patient the best possible care,” says Dr. Wassef.
Studies show that PGPs that successfully manage bundled payments are those that utilize certain strategies including: evaluating the patient prior to surgery to ensure they are a good surgical candidate, maintaining communication and engagement with the patient post-surgery, coordinating with hospitals and other care providers throughout the care continuum, and understanding the data supporting evidence-based care pathways and protocols.10,11
“You need to understand the total patient,” says Dr. Mittal in reference to the 90-day episode of care, stressing the importance of providing the right care, in the right setting, and at the right time. Another key component of the Orthonomics concept is utilizing tools and resources that can provide expertise in managing all the complexities of bundled payments for joint arthroplasty, including patient education and communication both before and after the surgery.
Orthonomics is relevant to the adoption of clinical and economic innovations that have the potential to make surgery more efficient and cost-effective, and to improve a patient's function and quality of life. One example has been robotic arm assisted technology in total hip arthroplasty (THA), unicomparmental knee arthroplasty (UKA), and more recently total knee arthroplasty (TKA). While the robotic arm does not actually perform surgery, the MAKO system software is used by the surgeon to create a personalized pre-operative plan.
According to Dr. Mittal, "in my experience the technology has been 'transformative' in providing a plan ahead of surgery to enable accurate and precise implant placement to plan and also in providing data for making appropriate treatment decisions.” In his practice, he notes less post-operative pain among his patients, less physical therapy post-TKA due to a well-balanced knee, and cost savings due to faster discharges.
Dr. Wassef echoes that in his experience the technology has been "revolutionary" and notes examples in his practice of fewer complications, decreased care, and cost variations within the 90-day episode of care.
Other innovations that can help drive clinical excellence, while achieving financial viability for PGPs, are those that can address critical practice management issues in an increasingly complex healthcare landscape, as well as promote patient-centered care. Fortunately for PGPs, practice management platforms have also kept pace with orthopaedic surgery’s regulatory and marketplace challenges. Such platforms and software can provide a range of customized practice management solutions, including ongoing financial and operational analyses, methodologies for improving practice efficiency and profitability, and strategies for maintaining practice sustainability in an evolving value-based environment.
Technology also plays a critical role in maximizing patient-centered care and physician-patient engagement throughout all stages of the care continuum. Websites for educating patients prior to surgery, smartphone and other mobile apps for monitoring patients post-discharge, as well as telemonitoring for patients living in rural areas are vital for providers like Dr. Mittal who has a large rural patient population.
As the transition to value-based healthcare continues, along with the increasing demand for joint replacement surgery, orthonomics can provide an important framework for identifying the elements integral to achieving practice excellence and economic viability. Some key takeaways:
Dr. Wassef and Dr. Mittal are paid-consultants of Stryker. The opinions and experiences expressed by Dr. Wassef and Dr. Mittal are not necessarily those of Stryker. Surgeon and hospital experiences may vary.
content ID number: GSNPS-WC-25_20448
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