Dr. Stefan Kreuzer's 80-year-old mom needed a hip replacement.
She was a prime candidate to undergo the procedure at an ambulatory surgical center and her son knew just the right facility: Houston-based INOV8 Orthopedics.
Mrs. Kreuzer’s total hip replacement took one hour, and later the same day she was up and walking on her way home. Now, she is one of the more than 300 patients INOV8 has performed a total joint replacement on and is a success story that sticks out in his memory.
Dr. Kreuzer started his career in private practice. At the time, all joint replacements were inpatient procedures, and surgeons generally did two a day, with patients staying a week in the hospital. After a decade in private practice, he was recruited to a hospital and given the goal to build a state-of-the-art joint replacement program.
"I meant a lot of money to the hospital," Dr. Kreuzer said. "The total joint program is what really drives revenue in the hospital. I started thinking."
He realized he wanted to perform joint replacements on his own and provide high-quality care, but at an affordable price. He wanted to build a center that would perform total joint replacement five days a week with patients going home every day, not just twice a week. He formed INOV8's surgery center in 2019 and partnered with Deerfield, Ill.-based Surgical Care Affiliates (SCA).
"What people don't understand is that doing an outpatient total joint is not moving a total knee from inpatient to outpatient," Dr. Kreuzer said. "You have to build a whole program. SCA had done that successfully in other parts of the country."
Marney Reid, senior director of SCA, viewed INOV8's goals the same way. She wants surgery centers to have booming total joint programs and knows the work it takes to get it done.
“We serve patients best when we help a facility and its physicians appropriately plan for, and support, all aspects of a total joint program”, she said.
INOV8 was a wild success. Dr. Kreuzer credits it to a mix of good staff, planning and patient selection.
"We spent a lot of time creating a good culture," Dr. Kreuzer said. When INOV8 hires an employee, it looks for a person who is going to buy into what the center is doing and be excited about it. The many nurses and employees at our practice are physical therapists helping patients get up after surgery and go home to recover.
In addition to ensuring a positive culture radiates through his surgery center, Dr. Kreuzer also optimized the patient selection process. Before any patient is a candidate for a joint replacement, they fill out a questionnaire that uses artificial intelligence to risk-stratify patients into a number of categories. The questionnaire weeds out patients who wouldn't be a good fit to ensure everyone is getting the appropriate level of care they need. INOV8 then puts all its patients through an education program, and then every patient meets their anesthesiologist before the procedure. Finally, post-procedure nurses follow up with patients to make sure they're recovering according to plan.
INOV8's total joint program is the beginning of a growing national trend. The baby boomer generation is expected to undergo more joint replacement procedures than any generation before it, and procedures are expected to continue migrating to the outpatient setting. For example, Dr. Kreuzer welcomed CMS' recent proposal to move Medicare total hip arthroplasty patients to the outpatient setting and believes if approved, he'll personally perform more total hips than knees.
SCA, too, is expecting growth of joint replacement programs. The company has approximately 60 facilities that have recently started performing or are in the process of developing total joints, and it developed a dedicated in-house team that helps centers that want to start a program get up and running. To capitalize on the coming joint replacement boom, SCA and Dr. Kreuzer know cost control is important.
To that point, SCA spent several months on a national implant initiative. The management company brought in a number of physician partners and 10 different implant companies to discuss ways to get implant costs under control across all its centers. By aligning physician partners and creating common expectations for vendors across its entire network, SCA has successfully implemented national contract pricing that reduces the supply cost while providing clinical choice.
When Dr. Kreuzer was thinking about establishing a low-cost, high-quality joint replacement program, he was ahead of the curve. Now a year into it, the program has doubled its volume and is expected to continue sustained growth. At the core of the program, though, were countless hours of planning and execution. It was a takeaway SCA took to heart and is one of the first things the company shares with centers looking to develop similar programs.
"[Joint replacement] is a feasible service line to launch, but it can't just be launched by scheduling a case and figuring it out as we go," Ms. Reid said. "As an industry, we owe it to our patients to ensure there is a stringent level of scrutiny and evidence-based best practices in the planning and launch of the program."