TOTAL TEAM APPROACH Dr. Andrew Stoeckl, MD, with physician assistants Jason Hooper (left) and Allison Fout operate at the Buffalo Surgery Center in Amherst, NY.

Check out these eye-popping predictions if you're considering adding outpatient total joints: The demand for knee and hip replacements is expected to increase by nearly 700% and 200%, respectively, by the year 2030. "There isn't capacity in the current healthcare system to accommodate that dramatic jump in volume," says Mark Wolbert, director of business development and marketing at Excelsior Orthopaedics in Amherst, N.Y. "And it isn't necessary that all those patients undergo surgery in an acute care setting."

Excelsior just wrapped up its first year of hosting same-day total joints, performing approximately 45 hip, knee and shoulder replacements in a physician-owned surgery center. Next year, when the program is in full swing, the surgeons hope to replace 100 joints. Excelsior is now reaping the benefits of a plan that was put in place several years ago. "We're well positioned as surgery evolves and more complex procedures move to the outpatient arena," says David Uba, MBA, Excelsior's CEO. "Now's the time to prepare your facility for tremendous future growth in joint replacements. If you're not proactive, you'll be left behind."

How to Build a World-Class
Outpatient Total Joints Program

Learn how to add outpatient total joints during a special workshop run by Excelsior Orthopaedics at OR Excellence, which will be held October 11-14, 2016 at the Hyatt Regency Coconut Point in Bonita Springs, Fla. Register at www.orexcellence.com.

Clinical considerations
Orthopedic surgeon Andrew Stoeckl, MD, president of Excelsior's board of directors, backed the shift from inpatient to outpatient from the clinical side. He specialized in knee replacement at the local hospital for years before wondering if the procedures could be performed safely and effectively in the surgery center, and challenged the business office and clinical staff to help him make it happen.

It was a gradual evolution. Dr. Stoeckl saw a select group of patients in the hospital who did really well post-op day 1, leading him to weigh the possibility of pushing the envelope to shift the procedures to the outpatient setting.

He says patient selection is the first and most critical clinical consideration. Identify patients who are prime candidates for outpatient procedures by assessing their medical comorbidities, level of family support at home and pre-op narcotic use (they should be narcotic na??ve).

"Once you figure out patient selection criteria, embrace the concept of multimodal pain management in the ambulatory setting," says Dr. Stoeckl.

His patients receive the NSAID celecoxib in pre-op. Anesthesia providers then place adductor canal blocks, which provide analgesia without significantly inhibiting motor function at the joint. Dr. Stoeckl has embraced local bupivacaine liposome injections, which he calls "game changers" for patient recoveries. He also gives patients tranexamic acid, which decreases hemarthrosis, bruising and swelling — several factors that impact pain.

Excelsior set procedure-specific case volume threshold surgeons must hit before performing the procedures in the surgery center. For example, surgeons must perform 50 knee replacements a year before shifting the procedures outpatient. Surgeons have to be confident they can perform the cases in a timely fashion without causing significant trauma to the extremity, notes Dr. Stoeckl. Interestingly, he uses a standardized operative technique, so his inpatients also benefit from the continued evolution of his outpatient experience and protocols.

Once surgeons figure out the clinical side of things, the real work begins. "Ironing out the pain control and figuring out patient selection is the relatively easy part — that's what we do," says Dr. Stoeckl. "The hard part is figuring out all the details behind the scenes."

It takes a total team effort to get a patient to the facility, through surgery and recovered safely and effectively, but at the same time you need a surgeon champion to push the cause and get the staff energized to make it happen. "If it weren't for the people around me getting behind the effort, I'd still be talking about it," says Dr. Stoeckl. "It's easy to come up with the idea of total joints, but it takes a couple years to operationalize it."

Building blocks
Excelsior's surgeons hold a majority ownership stake in the surgery center, so they're able to control the coordination and collaboration of care, which is essential to making the program successful, says Mr. Uba, who adds, "We manage the protocols, the quality of care, the patient selection and even the pricing."

Three years ago the practice's surgeons and business staff studied pioneers in outpatient total joints, knew the physician-owners were performing joint replacements at the local hospital, looked at their successful orthopedic surgery center and decided they had the pieces in place to launch their own program. With a committed team of business and clinical leaders, Mr. Uba says you can get a program up and running in 18 to 24 months, maybe sooner.

Excelsior sank $150,000 to $200,000 into a table that allows a minimally invasive anterior approach to the hip, which helps patients recover faster. Upgrades to instrument trays, power tools and other equipment demanded an investment of well over $100,000. Tracking and measuring case outcomes is a major component of a new joints program, because the procedures are relatively new and payers want proof that the surgeries are safe and effective. Excelsior paid about $30,000 in patient-reported-outcomes tracking software, which collects perioperative and quality data such as rates of complications, readmissions and infections, as well as pain scores and activities of daily living.

ROOM UPGRADE Adding total joints requires a significant capital investment in capital equipment, instrumentation and power tools.

The investments are substantial but necessary if you're serious about running a successful outpatient joint program.

Getting paid
You can't run a total joints program if insurers won't pay for it. First assess the payers in your market to ensure they're ready to reimburse total joints in the outpatient setting, suggests Mr. Uba. Are they willing to consider different payment methodologies, including bundled payments? Do they have analytical capabilities for assessing the cost of an episode of care and evaluating whether what you're proposing to them is going to save them money, improve outcomes and increase patient satisfaction?

Mr. Uba says Excelsior's surgery center benefits from operating in a market with 3 strong local payers — Blue Cross Blue Shield of Western New York and the HMOs Independent Health and Univera — interested in the potential of outpatient joint replacement. The insurers had seen other cases shift from the inpatient to the outpatient arena and were understandably excited about paying significantly less than what they pay for joint replacements performed in the hospital.

A group of surgeons and Mr. Uba met with the insurers to educate their medical directors and directors of contracting and network about minimally invasive techniques, regional blocks, perioperative pain medications, advancement in post-op pain control and accelerated rehab protocols. "They wanted to understand why and how outpatient total joints are possible, and needed proof that the procedures are safe and effective," says Mr. Uba.

POST-OP PERKS
Joint Replacement Patients Recover in Style

THE SUITE LIFE Patients are discharged to a high-end condo, where their recovery is closely monitored.

Excelsior Orthopedics in Amherst, N.Y., schedules joint replacements for first thing Monday morning. Patients are ready for discharge around noon. That's when the fun begins — well, as much fun as you can have recovering from a major operation.

Patients are sent to a nearby high-end condo that Excelsior leases and remain in the lap of luxury until Wednesday surrounded by amenities usually reserved for a boutique hotel. Patients fill out a survey before their procedures, sharing everything from their favorite snacks to their preferred music. They walk into the condo after surgery as their favorite Pandora station plays on a flat screen television. The kitchen is filled with their favorite food and snacks. They have access to Netflix and Apple TV, and are welcome to order movies on the practice's corporate credit card. Patients order food from local restaurants that have partnered with the surgery center. Pull-out beds let family members spend the night as their loved ones recover. One surgeon recalls walking into what looked like a family reunion when he stopped by the condo to check on a patient after surgery.

"It's like a vacation," jokes Mark Wolbert, director of business development and marketing at Excelsior. "It's hard to get rid of them sometimes."

A registered nurse remains with the patient around the clock and a full-time physical therapist monitors the patient's progress during the critical first few days of recovery. The bundled payment Excelsior negotiated with local payers covers it all. "We want the recovery experience to be top notch," says Mr. Wolbert. "Why would you do it any other way? The feedback from patients has been awesome."

— Daniel Cook

The negotiations centered on bundled payments, which, Mr. Uba says, eliminate tediously negotiating fees for surgeons, anesthesia providers, the facility, rehab, recovery care, implants and supplies.

Excelsior now has bundled payments in place with all 3 payers. The bundles cover surgeon, facility and anesthesia fees, all aspects of perioperative care, a 2-day post-op stay in an offsite recovery suite, 15 physical therapy sessions and 90-day recovery care.

Excelsior performs the procedures for about 30% less than what the $15,000 to $30,000 local hospital charges. "We can divide the single payment any way we want," explains Mr. Uba. "It's enough to cover our costs, with some margin left over.

Forward thinking
Patients seeking joint replacements are significantly younger and healthier than when Dr. Stoeckl trained 10 to 15 years ago. Younger patients interested in maintaining an active lifestyle and quality of life as they age — Excelsior has replaced joints in patients in their 50s — and the new economics of health care have changed the philosophy of where these procedures should be performed. Dr. Stoeckl is energized and excited by the opportunity to add outpatient total joints to his surgery center. He says, "To actually be a part of it in our community has been personally satisfying."

Mr. Uba says the "moderately profitable" procedures achieve the triple aim objectives of healthcare reform — improving the patient experience, improving quality and outcomes, and reducing cost — and show patients that having the procedures done in an outpatient setting lowers complication rates, lowers risk of infection, results in faster recoveries and costs less, depending on their insurance.

Don't wait for the market to dictate what happens to your facility. "We're looking at how surgery is evolving and deciding how we'll innovate programs that can achieve the objectives of healthcare reform," says Mr. Uba, "so we're recognized as leaders and innovators in helping to drive and shape the healthcare environment.

"We created a different care model in our community that has attracted a significant amount of interest from patients," adds Mr. Uba. "Patients rely on the healthcare system to innovate and find ways to enhance outcomes, save money and improve their experience. We've done that here." OSM