5 insights on physician alignment, payer negotiation tactics for ASC total joint programs

When it comes to total joint in the outpatient setting, it is no longer a question of "Is it possible," but rather, "How is it reimbursed?"

At  Becker's ASC Review 16th Annual Future of Spine + The Spine, Orthopedic and Pain Management-Driven ASC Conference June 14 in Chicago, a panel of experts discussed reimbursement strategies for ASCs in total joint. The panel included:

  • Thomas K. Miller, MD, section chief of sports medicine at Roanoke, Va.-based Carilion Clinic;
  • Deepak Chavda, MD, orthopedic surgeon and founder of the North Richland Hills-based Texas Bone and Joint Center;
  • Chris Bishop, CEO of Westchester, Ill.-based Regent Surgical Health; and
  • Bill Wilder, director of outpatient solutions at DePuy Syntheses, a Johnson & Johnson company, as moderator.

Here are five highlights:

1. On embracing the total joint program. "I think that we can all agree that doing higher acuity cases in a lower acuity setting is safe and it is effective. Doing joints or a total knee or hip in an ASC is safe and can be done," Mr. Wilder said.  

2. On aligning physicians.  "For me, the biggest issue is trying to get the physicians to align in a common manner," Dr. Miller said. "Talking to physicians is like herding cats because they're all right, they're all the best, but you need to get them into the same room and let them come to a commonality. You can't tell them what to do. You have to give them the rotary arm and let them decide what is best for them as a group."

3. On the need for data transparency.  "Data is key because now … not only does the physician need to agree, the patient needs to agree. The surgical center needs to agree. The insurance company or the payer needs to agree. The joint suppliers need to agree. The employers need to agree." Dr. Chavda said. "Because ultimately the ... data is transferred from the physician to the employer, the insurance company [can and will] determine all of the direction [of care delivery and cost]."

4. On key steps to full reimbursement. "The first issue is you still have to prove the quality and value and we can all in this room agree that ambulatory joints are appropriate and safe ... [but] you have to have the numbers that can back that up. If you don't have those numbers, you got [no standing] in your negotiations," Dr. Miller said.

"[We have someone] on our team from the insurance industry, with previous experience [on the payer side], so we know what the insurance industry is thinking or how they evaluate the data or how they act on those things," Dr. Chavda said. "As a physician, I know more about the patient data, I know how my patients are doing and I give my data to [them to present]."

5. On staying ahead of the curve. "Surround yourself with great thinkers because our strategy 12 months ago wasn't very good. It is a lot better today and it will be a lot better in 12 months," Mr. Bishop said. "So make sure you have great consultants, accountants, physicians — a true team approach — because just clinical, just business, doesn't work. It has got to be integrated."

More articles on orthopedics:

Payers, hospitals turning to the ambulatory space for orthopedics

Dr. David Junkin joins Hackensack-affiliated orthopedic institute — 4 insights

New system for outpatient total hip replacement launches: 4 insights

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