Since Madison (Miss.) Physician Surgery Center launched its outpatient total joint program in 2015, physicians at the ASC have taken on more than 800 cases. Arthroplasty surgeon Jeff Almand, MD, performed 300 cases at the center in 2017 alone.
Because of the program's growth, the subsidiary of Jackson-based Mississippi Sports Medicine & Orthopaedic Center plans to move to an eight-operating room facility in Flowood, Miss. The new center will be devoted exclusively to orthopedics and is slated to open in March 2019.
Dr. Almand, ASC Director Meredith Warf and Mississippi Sports Medicine & Orthopaedic Center CEO Glenn Silverman spoke with Becker's ASC Review about the program's success, challenges and trends for the future.
Note: Responses have been edited for length and clarity.
Question: How did you launch your outpatient total joint program?
Dr. Jeff Almand: Keith Berend, MD, and Mike Berend, MD, were two physicians at the forefront of outpatient joint replacements, collecting some of the initial data. I followed their data closely for the first couple years. All the data collected indicated we could do it safely and that it worked — that the complication rate is lower, the patient satisfaction is higher. That's when we approached Blue Cross [Blue Shield] and began the conversations with them.
At the same time, we were collecting our own data on Blue Cross patients in hospitals and sending patients home the next day. We were able to generate good data in terms of low complication rates and things of that nature, so they agreed to do it. After we got Blue Cross on board, other commercial insurance carriers followed.
Q: How did you grow your case volume within just a couple years?
Meredith Warf: We have four physicians in our company that specialize in joint arthroplasty. MS Sports Medicine is unique in that all our physicians are subspecialized, meaning that our four physicians that do total joints, that's all they do. We have 100 percent buy-in from them to move the cases safely to the ASC, and word of mouth has spread about our success and lack of complications.
Q: What are some challenges you've faced, and how have you overcome them?
Glenn Silverman: Some payers were just not ready for this in the beginning. It took about two and a half years of objective data and market trends here and nationally to get them to the table. The payer was uncomfortable letting anything higher than a 35 BMI be done outpatient, and we had our anesthesiologists say they were comfortable taking those patients. With the health demographic of Mississippi, most patients have a BMI greater than 35 — so that was a challenge. One of the regional challenges is that we're such a rural environment and we're a regional player, so we get patients from all over the state. If you send these patients back and let them either rehab on their own or go to places we're not associated with, they don't have as good of outcomes. We've developed our own narrow network, so before anyone has surgery, we know where they're going for rehab. Those people understand our communication and quality expectations and how to contact us if there are any problems.
MW: Having our care coordinator out in the field making presurgery visits to patients' houses has been a big benefit. She is always accessible and coordinates each patient’s care from scheduling the surgery all the way until the 90-day episode of care is over. She's been able to steer them in right direction as far as what to do if they have questions and increase access to care — which can be a challenge here in Mississippi.
Q: How did you manage a challenging patient population?
JA: We have a very strict selection criteria. We [also] have two home health agencies that … agree to see patients on the weekend, which is key. [A] representative from each one is in our office every single day, and they're in direct contact with all the therapists out in the field taking care of our patients. If there's any issue at all, we get them in to see us right away or they send us a picture [of the issue].
GS: We follow the patient literally through their whole journey. In our bundles, we assume the risk if that patient goes back to the ER, and we assume the risk of readmission. That could be a big number for us, so we're very careful about our patient selection criteria and making sure we've done enough education so they know how to communicate with us — because if they can't contact us, don't contact us or choose not to, they end up back in the hospital.
Q: What's your advice for physicians looking to start an outpatient TJR program?
JA: Try it at least six months in a hospital first. If your patients are going home in two to three days, start sending them home the next day. It's all about communication — from the time the patient enters your office to the time the patient sees you in follow-up, it's an intense series of communication that has to occur and everybody has to be in their place, doing their job, or the whole system fails. … Everybody has to be on the same page. If you do that, then you can do it well.
Q: What do you anticipate for the future of total joints in the outpatient setting?
GS: This will be the national standard of care within the next two to four years. CMS' decision last year to allow knees to be done in an outpatient hospital setting is the first step toward this becoming the standard of care. We're anticipating that at some point, CMS will approve Medicare joints to be done in an outpatient ASC setting as well.
It took us two and a half years to get all the payers to the table, and within three months, we've signed every major player in the market to outpatient total joints, whether they be bundled or fee-for-service. That tells me the insurers are now looking at it as a national goal or initiative. So, I think you'll start seeing it [become] even more prevalent than you are today.