Tom Hunt, executive administrator of MidAmerica Orthopaedics with multiple locations in the Chicagoland area discusses his practice's experience after joining Advocate Heath Care and participating in the system's commercial ACO. Paul E. Levin, MD, vice chairman of the department of orthopedic surgery at Montefiore Medical Center in New York City, discusses his experience with the hospital's pioneer Medicare ACO and where ACOs are headed in the future. Barbara L. Bergin, MD, an orthopedic surgeon with Texas Orthopedics, Sports & Rehabilitation Associates in Austin, also gives her perspective on accountable care organizations.
Q: What role do orthopedic surgeons play in ACOs?
Tom Hunt: Orthopedic surgeons can specifically focus on realizing the greatest savings within ACOs by decreasing hospital length of stays, readmissions and use of the emergency room. Orthopedic surgeons play a key role in this process since certain procedures — such as joint replacement — require admission. If the surgeon and his or her team can be sure they have preoperative, intraoperative and discharge planning organized before their patient arrives at the hospital, length of stay will be controlled and discharge will be timely. Additionally, when partnering with a hospital or health system, orthopedic surgeons can work to increase savings and quality of care.
Another area we are focusing on in our practice is increasing the quality and timeliness of care with our orthopedic immediate care center. We opened up our orthopedic immediate care in February and we are seeing a steady increase in visits every month as patients are bypassing expensive ER care. Primary care physicians are realizing they can get patients into our practice utilizing the orthopaedic urgent care center thus coordinating timely and less expensive care.
Dr. Paul Levin: The Montefiore Medical center accountable care work group identified two diagnoses (acute low back pain and acute chest pain) as two diagnoses with excellent opportunities for both improving care and saving money. I am the chairman of our acute low back pain management group, charged to improve the care of patients with acute low back pain. If you look the management of acute low back pain care in the U.S., it's widely recognized that it's over treated with no benefit to the patient and associated with that is an excessive use of expensive medical services.
We've already embarked on this mission over the past year, even before we were officially an ACO program. The primary focus is on the education of primary care physicians and insuring rapid access to a spine specialist when the primary care provider believes it is warranted. Lectures are delivered at the primary care sites reviewing evidence based guidelines, red flags and the basics of performing an appropriate history and physical examination of the patient with acute low back pain. If you talk to PCPs, they are most excited about gaining a comfort a level in caring for these patients and streamlining the process for orthopedic evaluation.
Essentially what we've established in the pioneer ACO — which is a relatively small portion of our medical center's population — is develop an algorithm of how to approach patients with acute low back pain. It is a variation of widely published guidelines and algorithms based on evidence about treating acute low back pain patients. We are continuing to give lectures at the various primary care sites about the algorithm and how to streamline the process.
If there was a concern by a primary care physician who thought a patient needed urgent orthopedic evolution, we have made ourselves available by EMR flag, email or mobile phone call. Whatever the provider needs to care for their patients we will provide. In the first year, we haven't been contacted in this way, but it gives the primary care physicians comfort knowing they can get help for their patients if something changes.
Dr. Barbara Bergin: They're going to be a necessary part of any ACO. Orthopedics is almost a primary care field of practice. We don't just do surgery. Believe it or not, the majority of our practices are actually centered on the conservative treatment of musculoskeletal disorders and not doing surgery. Although many of our referrals come from primary care physicians, most of our patients are still self referred. Patients know they need to see an orthopedic surgeon and they prefer to get in to see us directly, and today if possible! We're one of the first specialties an ACO, HMO or multispecialty group is going to seek out for maximum efficiency and control of the patient's medical care.
Q: What are the common concerns for orthopedic surgeons about participating in ACOs?
BB: It's pretty much the same as our concerns about insurance companies, multispecialty groups, hospital practice purchases, HMOs and yes, the government; the loss of our ability to control the care of our own patients and to do what we feel is in the patient's best interest. Accountable care organization sounds a lot like health maintenance organization and that sounds a lot like capitation. They’ve all got the 'tion' part and that ends up sounding a lot like 'care restriction.' Most of us feel that we know what’s best for our patients and putting any of that care in the hands of those who do not directly care for them is counterintuitive.
Q: How has the transition to ACOs been difficult?
TH: Being a partner in an ACO has not been difficult for our physicians or staff. Participation is voluntary, but there is a commitment to collecting and monitoring data along with attending educational conferences.
PL: Doctors across the United States are concerned about changes in healthcare. I think everything is up in the air with the political climate. People recognize that things have to change because the healthcare system is costing too much money now. Everyone recognizes that we have to do something to control costs.
The American Academy of Orthopaedic Surgeons plans to be very involved in helping with the transition to ACOs. I know they have initially supported changes in healthcare in the United States, with some reservations, and they plan to be very actively involved in being advocates for appropriate musculoskeletal care for patients.
Q: What challenges are there for orthopedic surgeons participating in ACOs?
PL: The philosophy of ACOs is improved quality and being reimbursed as an institution for providing quality care, not higher quantities of care. Back pain is an ideal diagnosis because if you look at it, providing better quality care saves money and improves outcomes. Ultimately, it is envisioned there would be more primary care physicians who handle most of the patients' common musculoskeletal problems with fewer specialists necessary to take care of patients who require specialty care and operative intervention .
At this point, we are still in our infancy and our surgeons still see a lot of orthopedic patients with acute low back pain who don't need surgery. I don't think we have the numbers yet to say we've been able to decrease the number of patients our orthopedic surgeons see with acute low back pain. There hasn't been a dramatic shift in patient flow at this time, but that will definitely our goal and the goal in successful ACO models.
I am still going around to different primary care sites, and even though there is tremendous interest from the primary care physicians to learn about care for low back pain and manage those patients without sending them to the orthopedist, we haven't seen that full transition yet.
In the future, we will see an additional challenge related to patient satisfaction because common algorithms for acute low back pain to not recommend any imaging be performed when no red flags are identified. Unfortunately, many patients expect to be referred for MR evaluation because they believe it is necessary to identify what is "really wrong." Patients perceive that we aren't meeting their needs if we don't order the MRI or send them to physical therapy and instead suggest lifestyle changes or other methods for pain relief. When this happens, they will give low patient satisfaction scores. It's going to be an additional challenge to get these things integrated and working together.
TH: When ACOs assess their organizations and orthopedic surgeons it can be difficult to quantify quality with certain diagnosis and procedures. I think this is an area where there still needs to be thought and continued research and evaluation. It's easy to quantify the length of stay in the hospital or ER use, but it's more difficult to quantify quality outcomes. I believe this is a concern for many orthopaedic surgeons who are participating in ACOs. Certain procedures such as revision surgery and at risk patients with comorbidities increase the potential for poorer outcomes. ACOs and the payors who are monitoring results need to be cognizant of the variables in patient care.
Q: How do orthopedic surgeons and practices benefit from ACO participation?
TH: I think the biggest benefit is well coordinated care by both your partners and the ACO that includes primary care physicians and other healthcare providers. Even though the coordination has been there for years, I believe there is additional focus now and we are delivering better and timelier manner.
For example, we didn't initially partner with the hospital on the immediate orthopedic care at our practice. We developed and staffed the center and it quickly became evident to our partners that utilization of the center had both quality and financial benefits for patients and providers. They like the concept and the idea that there is a place for those patients to go with non-emergent conditions. Some ACOs have partnered with national chains like Walgreens or CVS with their clinics in order to decrease ER utilization. While we aren't a national company, locally we are providing a service that definitely helps with quality initiatives.
PL: If primary care physicians are comfortable educating and coordinating non-operative care for low back pain patients, orthopedic spine surgeons are able to spend more time in the operating room than in the office with patients who won't need their intervention. We may also see a decrease in unnecessary and costly tests. For example, an article recently published in Spine (vol. 37, issue 18) studied Washington state workers compensation patients with low back injuries. They were looking at whether early MRI imaging improved outcomes.
The study found that early MRI was not associated with better outcomes for the patients with acute low back pain and was associated with a longer period of disability. This is something that has been pretty evident to me over the years because MRIs show abnormalities which aren't clinically significant, but they concern the patient and provider if they aren't comfortable understanding the meaning of the MRI. This could keep the patient out of work longer than necessary and delay their recovery.
The MRI costs money, doesn't help in planning the management of the patient's care and may actually make them worse and delay recovery. This makes it abundantly clear that an early MRI should not be a component of the algorithm for the care of the patient with acute low back pain who has no red flags indicating the necessity for early imaging.
BB: I'm a physician. If I were looking at ACO models, I would prefer one managed by my own kind. I would also steer away from ACOs in which my care was overly managed by ancillary personnel. We're the primary care givers. Unfortunately many areas in the U.S. are going to run short on doctors and may be encouraged or even forced to receive care from secondary care providers. Administrative costs, which are necessary to manage these kinds of programs will certainly escalate, eventually consuming a large portion of the already contracting medical dollar.
Q: What do orthopedic surgeons need to look out for to make sure they don't become part of an ACO that would be more harmful than good?
BB: Patients and doctors should look out for ACOs which are not aligned with the patient's best interest. How's that for a loaded statement? ACOs, like HMOs have the potential to be patient care restrictors under the guise of patient care efficiency. Save money by decreasing services. It's that simple. Cost savings, risk sharing and efficiencies are often terms which gloss over the simple reality of care restrictions. This has the potential to put patients and physicians on the wrong sides of the mighty dollar.
We want to analyze the population of an ACO. A predominance of the chronically ill will make it hard for the risk sharers to work efficiently and demonstrate best outcomes.
Q: How has participating in the ACO impacted your practice?
TH: We work with primary care physicians more in managing the preoperative evaluation of the patients and the postoperative care management. That's a team effort between the primary care physician and the specialists and the discharge managers at the hospital. Orthopedic practices have been very attentive to the discharge planning historically and in ACOs they are placing considerable emphasis on education and the discharge planning process. We don't wait until the patient is in the hospital; instead, we do it more proactively on a preoperative basis. Before a patient presents for surgery, there is an understanding of where they are going after surgery and which facility or home they will are discharged to. We have that all set up in advance.
Patient education has also been a key component in the ACO. In our practice, we have all of our patients review their care plans. We have educational videos on 80 percent of the diagnoses we treat so patients and their family members can review them online. We attempt to educate every patient as possible on the type of surgery they will have and the care they will need post-op. Patients are definitely more informed, so they are a better participant in the procedure and rehabilitation postoperative course.
A better educated patient is going to progress through rehabilitation quicker and have less chance of complications.
Q: Do you think ACOs will become a more widespread model for orthopedic surgeons in the future?
TH: I think a lot of physicians are taking the "wait-and-see" attitude and they are monitoring the ACOs currently to see if it is the right organization for them to join. Recently, I saw a survey where 60 percent of surgeons feel ACOs could be detrimental to patient care. I think healthcare providers are somewhat pessimistic and may feel we have been pursuing the goals of ACOs already and that certain hallmarks of ACOs have been in place for a while. We have to ask ourselves whether this is something new or whether ACOs are just another name for partnerships that hospitals and physician providers have had in the past.
However, I think we have to be cognizant of the fact that we don't want ACOs to stifle innovation just by looking solely at the lowest cost implant or pharmaceutical. Our country prides itself on leading the way in healthcare; we lead in innovation and we want to maintain that title. Hopefully, participation in ACOs won't stifle that innovation.
PL: I personally believe that the ACO model will ultimately benefit both the surgeons and the patients. If the surgeons are seeing the patients who need surgical intervention, it will save time and money. Surgeons should be busy in the OR and if we are able to see the appropriate candidates for surgery, it will improve our practice and improve healthcare for patients.
If you look at the successful healthcare systems in the country — Kaiser, Geisinger, Intermountain Healthcare — these are all facilities that are in one way or another operating in the model where they are assuming risk and providing care, which is really what ACOs do, and better care saves healthcare dollars and improves income for the health care organization.
BB: I can see a trial period of ACO ascendance, during which time we discover that significant savings aren't realized and outcomes aren't necessarily improved. Physicians will slowly fall off the wagon and return to fee for service, albeit a lower fee for service. But its human nature to prefer getting paid for one's services, even if it's less. Frankly it doesn't sound right to get paid more for doing less. It's unfair to ask physicians to risk share in an aging population of patients with lots of chronic diseases like obesity, diabetes, hypertension and heart disease.
Do we ask the grocer to risk share in the produce department? No. The price I pay for my fresh avocado covers the loss of all those soft browning ones they'll have to throw away tonight. The grocer doesn't pay for them. But I'm used to going to the grocery store where I am assured I'll get that fresh avocado. And our patients are used to receiving the best care possible; when and where they want it, and they also have plenty of access to hungry attorneys. Soon the patients will gravitate to care providers who will practice outside the ACOs, HMOs and hospitals; the concierge provider.
That is unless the government barges in and takes control of the entire industry. That will be a lot easier if most of us are already working for them or for hospitals.
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Where Orthopedic Surgeons Fit in ACOs: 3 Experts Weigh-In FeaturedWritten by Laura Miller | October 01, 2012
One of the most sweeping changes concerning the healthcare system today is accountable care organizations. Hospitals, specialists, primary care physicians and insurance companies are all worried about how they will fit into this new model of care, which values quality over quantity through a pay-for-performance instead of a fee-for-service. However, some orthopedic surgeons and hospitals have decided to push forward with accountable care organizations and are finding the challenges minimal — and even seeing benefits — to participation.
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