What ACOs Mean for Orthopedic Practices, Surgery Centers: Q&A With Michael Redler of Orthopaedic & Sports Medicine Center

Michael Redler, MD, co-founder of and orthopedic surgeon at the Orthopaedic & Sports Medicine Center in Trumbull, Conn., discusses how he thinks accountable care organizations would affect orthopedic surgeons and ambulatory surgery centers.

Q: Has anyone in your area (Fairfield County, Conn., outside of New York City) approached you about joining an ACO?

Michael Redler: As far as I know, there is no movement yet to start an ACO in Fairfield County. But I expect it will come. As a template, all we have to go by right now is the healthcare reform law, which is sort of enigmatic about what ACOs would look like.

Q: If you were asked to join an ACO, what questions would you ask?

MR: I'd want to ask a lot of questions. For instance: Would they work for my patients? Would I be able to deliver the best care? Can I support my family with the payments I would receive?

Q: How do you think orthopedic surgeons would react to ACOs?

MR: Even if ACOs turn out to be beneficial for orthopedic surgeons, there would be a learning curve. Any time you see a major shift in healthcare policy, there is initial resistance. However, orthopedic surgeons would have reason to be skeptical. If you put in several expensive anchors to stabilize the shoulder, would someone say that was not necessary? Would there be a committee telling you what you can and cannot do?

Q: Is there a role for orthopedic surgeons in an ACO?

MR: "Maybe not" is my gut response. ACOs will require linear patient care, covering all steps of the process, including mental health. Every provider along the way will need to cooperate. How do you create the sort of group understanding you need to run an ACO? I worry about how much control the ACO would exert. Since orthopedic procedures can be relatively expensive, orthopedists might be under pressure to delay or deny care. There may be a thinly veiled attempt to ration care. For example, if the patient were getting extensive cardiac testing, would they still be allowed to get a hip replacement at the same time?

Q: What sort of orthopedic practice would be successful in an ACO?

MR: ACOs would probably prefer working with orthopedic practices delivering the full spectrum of care in the specialty. I believe our practice is well positioned for that. We're a large musculoskeletal care group with nine orthopedic surgeons who do a variety of procedures, such as hand surgery, trauma and spine. We also have a physical medicine and rehabilitation physician, a podiatrist, two chiropractors, two athletic trainers and a dedicated physical therapy team, including aqua-therapy. Almost all of us work at ASCs.

Q: How would surgery centers fit into ACOs?

MR: The ACO needs ASCs. Almost any procedure that I do is going to be more cost-effective in an ASC. I think hospitals making preparations for ACOs realize that. In a lot of areas, hospitals are investing in ASCs and partnering with management companies to operate them. But they will also need to bring independent surgery centers into the ACO.

Q: Private payors have been slow to contract with ACOs for spine surgery, even though this venue is safe and less expensive. Will ACOs, with their emphasis on savings, speed up coverage of spine surgery?

MR: If ACOs don't open the way for spine surgery, it would be some other model. Insurers seem to be coming around. We don't have contracts yet, but we have been talking about it with payors.

Q: How do you think orthopedic patients will react to ACOs?

MR: Patients will be skeptical. I expect some of them will confuse the ACO with HMOs. Patients didn't like HMOs because they controlled their access to specialists, but ACOs are different. While HMOs were controlled by insurers, the ACO will be controlled by the hospital or by physicians. It's still possible, however, that providers could be forced to ration care.