PLENTY TO GO AROUND Joseph Nessler, MD, believes surgery centers and hospitals can partner to meet a community's joint replacement needs.

Rather than fighting tooth and nail for total hip and knee patients, a surgery center and a hospital a mile apart from each other in St. Cloud, Minn., are standing shoulder to shoulder. As you'll see, a spirit of close cooperation rather than fierce competition could be the key to successful same-day joint replacement programs.

"Market share is important, but it's also important to send a message that we're not against each other, that we're supportive of patients having joint replacement surgery wherever it's appropriate for them to have it done," says Naomi Schneider, MBA, RN, ONC, section director of orthopedics at St. Cloud Hospital. "My mindset is that working together is a win-win. Having a win-lose mentality doesn't give the community what it needs."

Rising tide lifts all ships
Earlier this year, St. Cloud Hospital began sending hip and knee replacement patients home on the day of surgery after they spend a few hours recovering in inpatient rooms under the care of certified orthopedic nurses and staff physical therapists. The St. Cloud Surgical Center is hosting younger, more active patients who don't have the comorbid conditions that necessitate having their procedures done in a hospital. Both facilities are focusing on the patients they should be taking care of, and both are doing well.

Joseph Nessler, MD, of St. Cloud Orthopedics, which has a majority interest in the St. Cloud Surgical Center, helped revive the facility's outpatient joints program in 2014. Today, the surgery center is performing about 25% of the community's total joints. You'd think the hospital would be unhappy to lose one-fourth of its cases to the local ASC, but the hospital's volume has actually increased by 10%.

Dr. Nessler points to the halo effect his practice's investment in robotics has had on the hospital's overall case volume. The surgeons at St. Cloud Orthopedics market their use of robotics, which, they say, has increased the number of patients seeking surgery at facilities that use the technology (see "Is Robotic-Assisted Joint Replacement for You?"). That growing interest has brought additional patients into the center and has also increased the number of patients who undergo surgery in St. Cloud Hospital, which has also adopted robotics. "The entire volume of surgery is increasing," says Dr. Nessler.

At first, it was hard for Ms. Schneider to accept losing business to the surgery center. But then she realized how much patients would benefit if the competing entities worked together, and how important it is for the hospital to work with, instead of against, the only ortho group in town that still brings profitable cases to the hospital and has been a valuable partner in building the hospital's orthopedic specialty programs.

The relationship between St. Cloud Surgical Center and St. Cloud Hospital now includes community outreach programs headed by Ms. Schneider and Dr. Nessler. The pair conduct talks about the many benefits of outpatient total joint replacement and discuss which patients are best suited to undergo the procedures at the ASC and which should have their joints replaced in the hospital, based on their insurance coverage and comorbidities.

Ms. Schneider says most of the patients who attend the events aren't candidates to undergo surgery in the ASC, so the grassroots marketing has been an opportunity to grow the hospital's overall case volume. She's also used the meetings to promote the hospital's rapid-recovery program, which is designed for Medicare beneficiaries and patients with comorbidities who are borderline candidates for the outpatient setting. St. Cloud Hospital touts its ability to recover patients overnight and have them ready for discharge the morning after surgery. It's a niche program they can offer that the surgery center can't. "There will always be patients who have to stay overnight, especially with the increasing number of obese and sicker patients we're seeing," says Ms. Schneider.

Skin in the game
St. Cloud Surgical Center is currently in negotiations to partner with St. Cloud Hospital and, if all goes according to plan, the hospital would become a minority owner in the center by the end of the year. Dr. Nessler hopes that having the facilities closely aligned in the future will let them both focus more on growing overall outpatient procedural volume. "Our idea is to make sure that we move the appropriate patients to the surgery center," he explains. "That will offload cases to a less costly venue and free up capacity in the hospital as inpatient volume continues to increase. There's a lot of room for growth on the outpatient side, and the aging patient population still puts a great deal of demand on the hospital. Us working together is a good thing overall."

Dr. Nessler concedes that pulling off a collaborative effort similar to what's currently happening in St. Cloud will be more complex and difficult in communities where several orthopedic practices, surgery centers and hospitals are competing for the same big slice of the outpatient pie. He believes the biggest growth of outpatient joint procedures will take place in freestanding ASCs, and that hospitals must have some financial stake in those centers for the model to work. "If they don't partner with existing surgery centers, they'll fight the trend with their own ASCs," says Dr. Nessler. "But unless their centers are truly modeled after freestanding facilities, those efforts will ultimately fail." OSM