Steadman Hawkins' Dr. James Silliman: 6 Post-Reform Challenges Facing Orthopedic SurgeonsWritten by Laura Miller | May 12, 2011
James Silliman, MD, an orthopedic sports medicine physician and CEO of Steadman Hawkins Clinic of the Carolinas in Greenville, S.C., discusses six big challenges facing orthopedic surgeons post healthcare reform.
1. Collecting data for clinical outcomes. Healthcare reform will eventually require orthopedic surgeons to document clinical services in new ways, such as documenting clinical outcomes and the way they use resources for their care. These measures will most likely be monitored, especially if the surgeon is participating in an accountable care organization or another pay-for-performance reimbursement model. "The orthopedic surgery community is going to have to have outcome measures and evidence-based orthopedic care," says Dr. Silliman. "The systems and tools for us to do this aren't fully developed yet"
Some facilities have been using electronic medical records or other data collection technology, but most programs don't cover all details of the data. The new Health Care Administration and Planning surveys show that clinical care in the office, relative to the patient's experience, will also be part of the data surgeons will collect.
2. Practicing evidence-based orthopedics. At the moment, there isn't a large amount of strong evidence-based research that supports orthopedic interventions. However, strong studies have become crucial for receiving reimbursement for orthopedic treatments and surgeries, which has prompted research institutions to accelerate their focus on evidence-based studies. "We'll need to show a positive impact in clinical results as well as financial results so people can see both sides of the equation," says Dr. Silliman.
Dr. Silliman and his partners are beginning a partnership with Blue Cross that aims to validate and document clinical outcomes and report financial resources to improve patient and employer satisfaction. The partnership encompasses orthopedic surgeons, neurosurgeons, physical medicine specialists, anesthesiologists, pain management physicians, physical therapists, ancillary providers and other medical professionals. "We want to reduce the indirect cost of care, streamline it and make it manageable and timely for our patients," he says. "If we can all work together, hopefully we can reduce the cost of care and receive better outcomes."
The study will be examining which treatment methods are most appropriate for each type of patient, when an MRI is necessary, how long it takes before the patient can return to regular work and the costs associated with care. "We have developed our own technology on the I-pad to work in real-time with our physicians and cater to the specific physician-patient visit," says Dr. Silliman. "It will complement the EMR, but in order to do this, we had to customize a program to our assets and our own flow of care."
3. Becoming accountable for orthopedic care. As reimbursement for healthcare services continues to change, orthopedic surgeons will need to conduct their practice efficiently and increase patient volume because payors are unable to support the current system. "Reimbursement levels are going to put a lot of pressure on physicians and practices to become more efficient and have more visibility than what they have now," says Dr. Silliman. "There's also a move toward ACOs in what the Centers for Medicare and Medicaid Services and other payors are putting into place to try to move some of the risk or accountability over to provider groups."
Medical specialists, such as orthopedists, can participate in multiple ACOs, and the physician requirements for these types of arrangements are continuously evolving. "The requirements are very different from those associated with fee-for-service," says Dr. Silliman. "Physicians are going to have to be aware of and familiar with the requirements of the payors, or they'll have to opt out. For example, if you opt out of Medicare, you won't be taking care of those patients."
Private insurers are paying attention to Medicare reimbursement levels and often follow suit. The adoption of these new processes and expectations will occur over several years, but physicians should be aware of the changes before they take place.
4. Integrating with hospital systems. More orthopedic surgeons are becoming employed by hospitals in recent years, and it's becoming increasingly necessary for private practice or group practice orthopedists to form some type of relationship with hospitals in their community. There are several challenges to integrating care because hospitals aren't used to providing ambulatory services and they can increase the cost because they have more expensive staffing models, technology and equipment, says Dr. Silliman.
"Physicians have to be careful of fixed costs when they are entering into a financial agreement with hospitals," he says. "Fixed costs are fixed costs, and the hospital might not have the lowest cost of care. If you have to support a huge fixed cost inside the delivery system, you'll participate in covering that cost as well."
Orthopedic physicians employed or partnering with hospitals often take on the responsibility of working with the hospital on supply chain issues and lowering the cost of care. Measures for lowering the cost include decreasing the length-of-stay, telemedicine for chronic orthopedic services and increasing the utilization of non-operative treatment forms.
5. Lowering the economic impact of orthopedic care. People are often burdened with taking time away from work and high travel expenses when seeking orthopedic care. Some patients travel from rural areas into urban centers, but even if they are traveling from within the city, extra driving with high gas prices can put a dent in patients' wallets. Orthopedic surgeons need to take the economic impact of their care into consideration as they treat each patient. "Physicians are not exposed to the economic data they need to make decisions when they are with the patients," says Dr. Silliman. "But this is what patients expect and we should provide it for them."
To provide this information, surgeons must be aware of the costs associated with one treatment over another when they are making decisions. If one treatment is three times more expensive than another and they both produce the same results, the physician should choose the less expensive treatment method. "The perfect scenario is to have good evidence-based medicine that has a treatment algorithm where you know what the outcome will be and the predictable costs for care," he says. "Patients want to know how long they will be out of work with their condition, and we need to have good answers for that. They will also ask how much the treatment will cost with their copay and deductible, and how many visits they will need to make."
Surgeons should be able to tell patients what their payment will be with their insurance companies, and approximately how many visits to the various specialists they will need. For some physicians, automating this information and sending it to the patient via e-mail can help relay and reiterate this information efficiently.
6. Switching to 1CD-10. The medical community is preparing to implement a new diagnostic coding system, ICD-10, which will place several challenges upon orthopedic surgeons and their staff. "We're going from 17,000 codes to 141,000 codes for ICD-10 (according to the American Academy of Professional Coders) and physicians are going to have to get used to a new coding system, and cross links for CPT are going to have to be redone," says Dr. Silliman. "That's going to create a new work effort in a magnitude that we haven't experienced before."
Orthopedic practices must provide training opportunities for the billing and coding staff to update these codes, or outsource claims to a professional coding company.
Learn more about Dr. James Silliman.
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7 Healthcare Reform Changes Affecting Orthopedic Surgeons
10 Biggest Concerns Facing Spine Surgeons From Healthcare Reform
The Year Ahead: 9 Biggest Issues for Orthopedic Surgeons in 2011
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