Delivering value from a collaborative industry partnership

The transition to value-based healthcare is driving innovative payment models and new partnerships that will transform healthcare delivery. Physicians and surgery centers are now partnering with industry to drive down costs while continuing to deliver quality outcomes.

"The value in having an industry partner is that it brings them to the table. They become engaged in the whole discussion of what value is, and can develop the best products for the best economic value," says Mark Gittins, DO, an orthopedic surgeon at New Albany (Ohio) Surgery Center. "They can participate in the bundled payments with us, but they also have a responsibility; we need industry to bring something to the table, such as eliminating steps or costs, or helping us to become more efficient."

Dr. Gittins and Ron Singer, MD, an orthopedic surgeon at Surgery Center at Edgewater in Charlotte, N.C., both partner with Smith & Nephew to drive value-based orthopedic care at outpatient surgery centers. The following article will describe how the partnership with Smith & Nephew helped both physicians improve outcomes and patient satisfaction while growing their businesses with new technology and techniques.

Outcomes and satisfaction
Smith & Nephew has focused efforts over the past several years on product and education development that can enhance patient outcomes and experience. The company's robust and differentiated product portfolio including VisionaireTM, JourneyTM II Total Knee and NavioTM Robotic System allow surgeons to tailor their approach to each individual patient and develop a safe and effective outpatient joint replacement program.

The Visionaire Cutting Guides are customized total knee arthroplasty cutting guides that incorporate surgeon-specific preoperative planning aids to determine implant size, alignment and rotation prior to surgery. Integrating the cutting guides into standard protocol can eliminate several steps in the surgical process, reduce the number of instruments needed for a procedure and lower infection risk.

"We are eliminating 90 percent of the alignment outliers that we might have seen with the traditional implants and instruments. If we are doing the procedure more accurately, that will provide value for patients long term and because we are making bone cuts in three dimensions there are fewer soft tissue releases so surgeries are less invasive and patients can recover more quickly," says Dr. Singer.

The Visionaire Cutting Guides are associated with 24 percent reduction in OR time and lower costs; data from 2015 shows high volume Visionaire users participating on the Comprehensive Care for Joint Replacement bundled payment model had lower total episode of care costs, rehospitalization rates and post-acute care charges than non-Visionaire users.

Implants play an important role in patient outcomes and satisfaction; if the implant doesn't feel right, even if it isn't painful, patients aren't satisfied. During his 20-plus year career, Dr. Singer spent two decades using an implant that didn't always produce desirable functional outcomes. He switched to Smith & Nephew's Journey II knee implant to improve high flexion functional outcomes. The Journey II has a normal kinematic designation from the FDA, which translates to better high flexion functional questionnaire answers.

"For decades we could perform knee replacements that folks were happy with and they could do their normal activities, but now patients have more expectations of what they should be able to do with their new knees," says Dr. Singer. "They want to garden, hike and bend down into a squatting position to tie their shoe. Patients are more satisfied with the Journey II asymmetrical device instead of the traditional devices."

Dr. Singer is also piloting patient engagement software by [m]pirik which is available through Smith & Nephew. Ortho[m]atrix sends text messages to patient's cell phones between 30 days prior to surgery and 90 days after surgery with different messages and reminders along the way. "It's a one-way communication tool right now, sending messages and discussing expectations, but I think it's allowed patients to
be more engaged with us as we try to accomplish the 90-day bundle pathways."

The move toward value-based care is pushing higher acuity procedures into the outpatient setting; surgeons across the country are beginning to transition the appropriate selected patients to outpatient procedures for spine and total joint surgeries. In some cases, surgeons are able to perform these procedures safely in the ASC and patients either return home within eight hours or spend the night and are discharged the next morning.

"We are trying to become more innovative but at the same time be the high quality, low cost provider," says Dr. Gittins. "We are networking with industry to produce better results at a lower cost. We're also managing the transition to outpatient surgery with spine surgery and total joint replacement. That's something we've been working on for years and now it looks like it will become a reality with CMS and private payers, but it will take meetings with industry partners to make that transition a reality."

Safety and efficiency
Surgeons and healthcare organizations are entering into alternative payment models, including bundled payments, designed to improve outcomes while lowering the overall cost of care. Dr. Singer and his colleagues in North Carolina participated in the CMS Bundled Payment for Care Improvement Initiative, a 90-day episode of care for total joint replacements. However, BPCI efforts quickly spilled into the fee-for-service caseload and the surgeons saw an increase in quality overall by implementing the best practices and strategies for high quality, low cost across the board.

"The fact that we are working with the post-acute care bundle, the Medicare bundle, that creates a mindset that carries over to all our patients," says Dr. Singer. "It has really forced us to look at our approach and become more cost conscious while preventing wound complications, readmissions and nursing home admissions when possible. Instead, we are discharging patients home."

To achieve success with the bundled payments, first healthcare providers seek to eliminate waste and increase efficiencies in the care process. Smith & Nephew partnered with the surgeons of Surgery Center at Edgewater to deliver custom trays, reducing the number of open trays in the operating room. The more efficient instrument trays only include the instruments surgeons will need for a particular case, and decreasethe amount of instruments to sterilize postoperatively.

"ASCs can be a challenge because they don't have as much square footage as the hospital," says Dr. Gittins. "Our storage and sterile processing areas are small. We only wanted to open two trays, so Smith & Nephew stepped up to the challenge and reduced all our instruments into two trays for us. With that, we aren't spending near the amount of time in central sterile or prep and we are much more efficient."

Intraoperatively, Smith & Nephew's Visionaire implant allows surgeons to perform a more customized procedure with a reduced risk of complications and readmissions. Under the bundled payment program, healthcare providers are at risk for additional care beyond the initial surgery, meaning any readmissions or additional treatments are on their bill. Surgeons can optimize patients for surgery with Smith & Nephew's patient engagement software.

Dr. Singer is utilizing S&N's unique Advanced Wound Care technologies with his outpatient joint replacement cases to help minimize the risk of postoperative surgical site infections. S&N's ASC GO! program bundles PICOTM disposable negative pressure wound therapy, and ACTICOATTM silver antimicrobial dressing with the joint implants. The use of PICO & ACTICOAT may reduce the incidence of SSI's by 95 percent in joint replacement cases.

Smith & Nephew guarantees their implants and provides financial packages for capital purchases. Dr. Singer's group participates in the guarantee program, but in their first 43 procedures, they haven't reported any infections or wound complications. "I'm happy to say we haven't had to take advantage of that program, but it does provide a type of insurance policy for us to know that we aren't going to have the exorbitant expenses if we have to go back to the OR during the global period," he says.

Growth and development
Patient volume is critically important for independent physician practices and ASCs to thrive. Smith & Nephew provides healthcare economics and customer-centric field support across the continuum of care as well as unique products for surgeons to build their practice around. For example, Dr. Gittins uses the Navio Robotic System and has grown his business due to increased efficiency and superior outcomes.

"We have become more proficient with unicompartmental knee replacements with the robotic system; it makes the procedures much more predictable," says Dr. Gittins. "Because the procedure is accurate and reproducible, we can have additional volume driven toward us. It's easier to perform the procedure outpatient with the robotic technology and we have been able to expand our program."

Surgeons at New Albany Surgery Center performed 58 unicompartmental knee surgeries with the Navio system within the first six months of acquiring the technology in 2015, a 729 percent increase year-over-year. Based on this experience, surgeons at New Albany Surgery Center are able to perform unicompartmental knee replacements in the same amount of time with the robotic technology as without, and the experienced surgical team performs the procedure efficiently. Dr. Gittins is now working with Smith & Nephew on a comprehensive market development plan using Blueprint, the proprietary Navio Robotics Program marketing toolkit.

As part of the BluePrint marketing program, S&N built a comarketing structure and growth rebate program to help Dr. Gittins offset the cost of patient outreach and marketing. The program injected new energy into Dr. Gittins' efforts to build his business. "Smith & Nephew has brought enthusiasm and man power to our program as we try to educate visitors that come through our ASC and helped us set up educational opportunities for people who aren't aware of the outpatient world," says Dr. Gittins. "They are helping us solidify our program."

One of the key co-marketing elements is the patient seminar; the center's first patient seminar about the robotic technology drew 107 attendees, some of which became patients. "That gets the information out to people who are interested in surgery and mobilizes them," says Dr. Gittins. "That's the first step to finding options for people in pain. The first event was wildly successful and we are optimistic about the future." The partners also embarked on more traditional advertising in the Yellow Pages and online.

Dr. Singer has also seen patients arrive at his practice to take advantage of the Visionaire technology." From a marketing perspective, the Visionaire patient matched technology allows us to draw patients in who really want to apply the technology as it relates to their anatomy," says Dr. Singer.

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Delivering value from a collaborative industry partnership


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