Tips for Taking on Total Shoulders

Shoulder replacements were already moving strongly in the direction of outpatient facilities before the pandemic hit. Within the outpatient world, I've seen a steady move to freestanding centers as opposed to hospital-based outpatient departments (HOPDs). Now the pandemic is hastening these shifts even more, as we try to keep patients away from hospitals that treat COVID-19 patients.

I've done some elements of outpatient shoulder surgery since my career began in 2002, and we've come a long way. In the nearly two decades since, I've become much more comfortable performing shoulder surgeries inside ASCs, to the point where I now perform the vast majority of them at our centers. I'm quite confident at this point that almost all the procedures I perform as a shoulder surgeon can be done in an ambulatory setting — provided the patients are medically appropriate.

If you're running a surgery center that performs shoulder surgeries, or thinking of opening one, let me share some clinical and business ideas that have been successful for us:

• Patient selection. You need to figure out which patients are most appropriate for your facility. We maintain strict exclusion criteria for our shoulder patients, with a particular focus on BMI and other significant comorbidities. For instance, a BMI of 40 or higher is a red flag. It doesn't necessarily exclude the patient, but does warrant further examination. We'll also instantly exclude a patient with a heart condition who might require a higher level of perioperative care, an extended hospital stay or potential readmission. Trying to comb out exactly how bad is too bad? is the next frontier for our practice. We're currently looking at ways to somehow increase safety in order to admit riskier patients. But if you're just starting out with outpatient total shoulders, you likely want to err more on the side of caution — at least initially.
• Regional blocks. Place a heavy emphasis on regional anesthesia for your shoulder patients. Compared to 15 or 20 years ago, anesthesiologists have gotten much more efficient at performing regional, and the effectiveness and duration of these blocks are much better. It's become much more streamlined. We've been proactive in terms of trying to provide a multifaceted approach to perioperative pain control. We generally combine sedation with an interscalene regional anesthetic block in order to help lower morphine equivalents postoperatively.

The feedback from patients is very positive — largely due to education on the front end. There's been so much publicity about the opioid crisis, and people want to avoid narcotics and opioids, so they buy into the multimodal approach much more readily than they did in the past. That's been a huge improvement in the last two to three years. With combined anesthesia techniques, I've been able to do shoulder surgeries more safely, with reduced usage of opioids and other narcotic medications.

• Bundled payments. Over the last three to five years, we've been transitioning to a bundled payment program for our total joints, which I view as a win for everyone. The patient stays away from the hospital where COVID-19 is being treated. From a cost standpoint, bundled arrangements offer potentially drastic benefits to our healthcare system, as they're proven to be more cost-effective.

Historically, Medicare reimbursement rates have been incrementally higher in hospital-based settings than ambulatory settings, with facility fees, anesthesia fees, etc., billed at a higher rate. I think that landscape is going to change because the government realizes things can be done more inexpensively away from hospitals. As we gather data, CMS expects a push to safely move more cases to ASCs. They're starting to realize there's greater interest in terms of which Medicare patients can eventually be pushed into ambulatory settings. From a joint replacement or arthroplasty standpoint, this model has enabled us to create a bundled payment program that works extremely well, because our physicians and administrators are allowed the creativity to construct initiatives that control costs. In turn, that allows us to have some say in terms of how we construct contracts with vendors, and how we agree upon standardized methods of care that help lower costs. It can be a real gain for the system.

• Price transparency. With our total joints bundle, which we dubbed EXCEL Orthopedic Surgery and Recovery Program, our patients know right off the bat what the cost of their total shoulder surgery will be: $24,500. That price covers everything — total care, from day one till you're fully recovered, including your rehab and a private recovery suite. Patients know going in exactly what to expect, and they receive one simplified bill. The goal obviously is to reduce the cost of health care and, in our experience, you usually save about 30% versus a traditional hospital stay by going through our program. The feedback has been tremendous from patients who have qualified for and elected to do it.
• Care suites. Our shoulder total joint procedures are done outpatient, but they're not same-day. To ensure a safe recovery, we keep total shoulder patients for less than 24 hours — but not in a PACU bay. As part of the $24,500 bundled price, patients and their companions stay the night in one of our private care suites, complete with kitchenettes, which we own and operate. Patients love it because they stay out of the hospital and enjoy a much quieter environment in which to recover — more like a hotel room or apartment than a hospital room. They have 24-hour access to nurses on site, and their vitals are monitored, so we're able to give them safe medical care at a moment's notice.
• New tools and technologies. When you talk about total shoulders, you can't forget the tools and technologies currently available — like navigation- or pre-operative-planning templates that use CT — as well as the compelling products in the pipeline. But you don't want to invest in new technology simply because it's new; there must be some tangible, data-backed benefit. Because we're so focused on our bottom line as an outpatient facility, we're highly strategic and informed about new additions to our toolbox, because we just can't afford them to be money-losers. When we're evaluating something new that has incremental cost, we're motivated to look at it from an evidence-based point of view and ask, "Does this added cost make a difference?"

The majority of the action in shoulders is on the biologic augmentation front — growth factors, tissue augments, scaffolds, for example. I've been using some of those in selected situations, but most require more study to determine whether or not they will become widely used. For example, there's interesting potential in augmenting a shoulder repair with a bone marrow aspirate stem cell injection that, in addition to the patient's own biologic tissue, could be laid onto a repair to enhance healing. But that's a largely theoretical benefit right now; we still need more data.

No going back

The migration of total shoulders from an inpatient procedure to outpatient surgery is gaining momentum. I don't see most shoulder replacements going back to inpatient ORs. There's too much good data and experience on the part of insurers, who realize the cost benefit; patients, who prefer the outpatient setting; and surgeons, who enjoy specialized infrastructure and staff. For us, everything at our centers is about orthopedics, which results in cost efficiencies in terms of having consistent equipment as well as consistent staff from admission to pre-op to the surgical suite to post-op. My surgical techs and circulating nurses are very comfortable and familiar simply because of the repetition of what we do. There's so much efficiency in this model. Bottom line: The government and insurers are saving money by shifting shoulder replacements from inpatient to outpatient. It's a significant cost differential, and when you multiply it by an exponential factor, it can be a potentially huge benefit to the healthcare system overall. OSM