MINIMAL TRESPASS Smaller-incision, muscle-sparing surgical techniques for joint replacement contribute to a successful surgery and recovery.

Jeannette Moretti, RN, remembers what hip replacement was like 15 or 20 years ago, back in the old days when total joint surgery was very invasive, pain control was primitive and the patient was immobile for days. Admitting these patients the night before surgery and for 3 or 4 nights afterward was necessary. Surgery took a minimum of 3 hours and required 10 to 12 instrument trays. Following hospital discharge, some patients would require further care at a rehabilitation facility.

My, how times have changed. Fast forward to today and it's get hip, go home.

Patients arrive 2 hours before surgery. It's wheels in, wheels out in 90 to 100 minutes. Depending on the implant, you can get by with 4 to 8 size-specific instrument trays. And thanks to muscle- and tendon-sparing surgical techniques and innovative pain management protocols, patients are back in their recliners before they know it. They spend 2 hours in PACU and 1 overnight in an off-site recovery suite before they're discharged home.

"It's come a long way since I first started doing hips 20 years ago in the hospital," says Ms. Moretti, director of the Buffalo Surgery Center in Amherst, N.Y., which has developed one of the country's top same-day joint replacement programs and recently christened a 28,000-square-foot multi-specialty surgery center with 4 ORs dedicated to total joints and a $200,000 OR table that's specifically designed for an anterior approach during hip replacement, a muscle-sparing technique that leads to the faster recoveries.

Buffalo Surgery Center launched its same-day total joints program nearly 3 years ago, one of the first freestanding facilities to offer same-day discharge. Of Buffalo's total joint volume in 2016, hips represented 46%, while knees were 54%.

Of the 340,000 hip replacements performed annually in the U.S., it's becoming increasingly common for patients never to step foot inside a hospital. Buffalo's surgeons rehearsed and honed their same-day total joint protocols in the hospital — working on ways to send patients home even though they weren't — and then conducted start-to-finish dry runs at the surgery center until they'd mastered all the elements needed for same-day discharge: reliable pain control, exquisite surgical technique and at-home rehab programs.

"Our doctors looked at different programs that were doing total joints and sending patients home the next day and were very interested in it," says Ms. Moretti. "They asked: How can I send these patients home? That's how it all started. Other people were doing it. It's good for patients. Let's see if this works for us."

$26,735 BUNDLE BREAKDOWN
Unraveling the Bundled Payment

FIXED PRICE Under a bundled payment model, hip replacement is reimbursed with a single all-inclusive fee.

Let's say Buffalo Surgery Center receives a $26,735 bundled payment for each hip arthroplasty. This all-in, fixed-price payment covers all services during an "episode of care" that extends from the surgical discussion through 90 days global post-op. Services excluded from the bundle include pre-op testing and medical clearance, MRIs, hospital re-admissions due to complications, post-op pharmacy costs and revision procedures. Here's a line item look at what's included in the bundle.

Cost

Service

$10,000

ASC facility fee and supply costs *

$4,000

Surgeon's fee

$400

Surgical assistant's fee

$1,800

Anesthesia fee

$1,500

15 physical therapy sessions

$200

Durable medical equipment **

$6,600

Post-acute care ***

$2,000

Physical therapy

$235

Post-op care ****

* Facility fee includes $5,000 allowance for implant.
** DME includes walkers, canes, ice machines and DVT compression sleeves.
*** Post-acute care includes home care, 1 overnight at the recovery suite, meals and nursing.
**** Post-op care includes 3 post-op office visits and 2 X-rays.

Saving a bundle
Hip and knee replacements are Buffalo Surgery Center's most profitable cases — and by a wide margin.

Based on an estimated bundled payment of $26,735 for total joint arthroplasty, each of the 76 hip arthroplasties it hosted last year returned profit margins anywhere from 25% to 45% ($6,683 to $12,030). Yet the bundled payment is 30% to 35% less than the cost of inpatient hip replacement in Western New York.

"That's why payers love the bundled payment," says David Uba, MBA, chief executive officer of Excelsior Orthopaedics and Buffalo Surgery Center.

Some say such a disparity in charges is a testament to the economy and efficiency of outpatient surgery, and an indictment against the exorbitant cost of elective surgical care in hospitals.

"It's interesting that the bundled payments we've negotiated with payers have put pressure on the rest of the providers in the community to lower their episode-of-care cost for joint replacements," says Mr. Uba. "The payers are using our program as a model to approach hospitals and physician groups to say, "Look, these guys can do procedures at this cost. Why can't you?'"

Besides enhancing reimbursement for surgeons (see "Unraveling the Bundled Payment" on the right), bundled payments shift control back to where many think it belongs: with physicians.

"The true value of the bundled payment model is that it gives you more control over the flow of dollars and the flexibility to redistribute where those dollars are going," says Mr. Uba. "For too long, the person providing the care had no control over outcomes, quality and costs."

Bundles also incentivize physician-owners to get much more engaged in implant negotiations and in managing case costs — especially expensive implants. "Doctors didn't necessarily care what an implant costs in the hospital — they got the same fee regardless," says Mr. Uba. "Docs now have a vested interest in the cost of an implant. Money they save goes straight to their own pockets."

One strategy to control implant costs is to cap what you'll pay, says James D. Slover, MD, an orthopedic surgeon at NYU Langone Medical Center in New York. "Tell vendors that they're welcome to sell their products so long as the price doesn't exceed X," says Dr. Slover. Also include a clause in your purchasing agreement that there will be no hidden or extra fees for certain size implants or for using a certain screw, he adds.

Ms. Moretti says it's best to buy all your implants from a single vendor. "Implant costs will make you or break you," she says, "Just like with any supply, if you give the implant company more volume, it'll be more willing to negotiate price." Of course, for this to happen, your surgeons must agree to use the same type of implant, she says. Find out what area hospitals are paying for implants. "There's ways to find out," she says — from asking patients for their EOBs to asking your colleagues.

Is the anterior approach superior?
The anterior approach is the shortest and least disruptive way to reach the hip. The surgeon needs to make only 1 incision, and is able to do so without detaching muscle from the pelvis or femur.

"There's less muscle and soft tissue to fix after the joint is replaced, which is one of the main reasons patients can ambulate soon after surgery and prepare for same-day discharge," says Richard B. Schultz, MD, director of orthopedics at Scott & White Healthcare in Round Rock, Texas.

Another significant advantage of the anterior approach: You can place patients in the supine position during surgery. Because patients are lying flat on their backs, anesthesia providers and surgeons are more comfortable performing the procedure using spinal anesthesia and without having to intubate. Most traditional hip replacement surgeries are done with patients on their sides, which makes it difficult to establish the airway in emergent situations. With the anterior approach, the anesthesia provider doesn't have to give the patient as much medication preemptively to secure the airway, and that means patients will be ready to recover that much faster.

"There's an old surgical adage that says you can do whatever you want to the bone as long as you respect the soft tissue," says orthopedic surgeon Tyler Goldberg, MD, of Texas Orthopedics. "If you don't cut any muscles, patients will rehab twice as fast. They'll be off of pain pills inside of a week. It's just night-and-day difference."

Recover + rehabilitate in style
Buffalo Surgery Center leases a 2-bedroom condo in a high-end apartment building minutes from the surgery center. It is here, in the surgical recovery suite, where joint replacement patients spend the night after surgery and have their first physical therapy session as well as visits from a nurse.

Talk about your amenities. There's gourmet room service. Patients get a private bedroom and walk-in shower. There's ample room for overnight guests (family members are encouraged to stay with patients at the suite). Patients also have access to an indoor pool, spa and 24-hour fitness center.

Such luxurious accommodations are fitting, says Dr. Slover, because most hip replacement patients don't feel sick. "They're healthy patients motivated to recover faster," he says, "and they enjoy the ability to recover at home." OSM