Healing Ourselves: An MD's Idea to Make Care Better

Introduction

             The Centers for Disease Control estimates that nearly 55 million Americans have been diagnosed with arthritis with the number expected to increase to 78 million by the year 2040. An aging baby boomer population that is living longer and less accepting of physical limitations has increased the demand for treatment of arthritic disorders. As a result, hip and knee replacement surgeries have become a major financial burden to Medicare costing upwards of $7 billion per year. Some have predicted that demand for arthritis care will soon outpace the ability of the health care system to provide it. In response to increasing demand and increasing costs associated with joint replacement care, CMS has instituted several programs aimed at shifting the paradigm of care away from the traditional “fee-for-service” model to a “pay-for-performance” model. Alternative payment models, bundled care initiatives, and other similar programs are designed to reward stake holders for reducing costs and improving quality. Early results have been mixed results and concern for diminishing returns remains. Commercial insurance companies have begun to follow suit with similar quality-based incentive programs through Center of Excellence designations aimed at directing patients towards high quality, low cost providers.  

Despite the potential for these programs to reduce the cost burden of delivering arthritis-associated medical care, several challenges remain. Many bundled and alternative payment models represent a “race to the bottom” in which maximum efficiency may be achieved quickly (within a few years) with price goals rapidly becoming unattainable. Furthermore, cost savings from these programs may not be as robust as first thought. The effort to reduce cost may suppress evolving and innovative techniques, devices, and technologies that are deemed too expensive, thus stifling innovation. In addition, newer payment models often fail to account for challenges associated with treatment of high risk patients thereby punishing providers who care for a less healthy patient population. Concerns regarding “cherry picking” of healthier patients and “lemon dropping” of sicker patients remain. 

             Shifting healthcare economics have made it difficult for smaller, low volume hospitals to deliver cost effective total joint care. Orthopedic service lines have traditionally been a significant generator of revenue for hospitals; as those cases migrate to high volume, large hospitals, smaller community hospitals will either lose financial viability or will be forced to join larger health systems (by acquisition or affiliation). While in theory large health systems have the ability to use pooled resources, economies of scale, and integrated networks of care to improve quality and drive down costs, the opposite has often proven to be true. Large health systems reduce competition, increase administrative burden, and often use their leverage and negotiating power to increase price and decrease patient choice. As the pool of healthcare dollars available for the treatment of arthritic conditions continues to diminish, hospitals and health systems will need to find additional means to drive down the cost of care by reducing implant costs, reducing investment in new technology, acquiring physician practices, and instituting risk-sharing models with providers.

             Despite numerous studies showing that specialty and physician-owned hospitals improve quality and drive down cost, the PPACA/Obamacare placed a moratorium on new POHs and prevented expansion of existing facilities. However, recent challenges to the PPACA and a renewed interest in POHs may soon lead to a change in this policy. Smaller, specialty focused hospitals deliver high quality, cost-effective care and are able to achieve the goals of APMs and BCPI in a sustainable manner. A specialty facility may reduce administrative burden, improve patient experience, reduce physician and employee dissatisfaction and burnout, and avoid other limitations and obstacles present in large hospitals and health systems.

             In summary, the delivery of medical care for arthritis, particularly of the hip and knee, is at a critical crossroads. While the need for arthritis-related services is expected to increase significantly, the current systems are ill-equipped to meet this demand and/or achieve the goal of delivering high quality, cost-effective joint replacement care. While newer models such as APMs, CJR, or BCPI may provide a short-term solution, they are likely unsustainable and may not go far enough in addressing the problem. Hospitals and health systems will be forced to grow larger to remain viable amidst a climate of declining reimbursement and increasing pressure to reduce costs. However, these large systems may paradoxically increase cost to the patient/consumer while reducing patient choice and limiting physician autonomy. The aging of the baby boomer population coupled with the inability of the current system to keep up with demand could lead to a crisis in hip and knee arthritis care. To avert this potential crisis, a unique approach to care delivery may be necessary. In 2019, stakeholders such as state governments, CMS, and insurance companies are beginning to understand that current models fail to address the coming problem and may be more receptive now to ideas that challenge past paradigms and represent a way forward.

             The concept of disruption, commonly applied to the technology sector, involves the introduction of a product, idea, or service that challenges existing norms. Disruption forces change in established business models by providing innovation beyond currently established practices. In 2007, Apple disrupted the mobile phone market by introducing the first iPhone at a time when BlackBerry and Motorola dominated sales and few consumers were aware of the existence of smartphones. Just 12 years later, Apple now accounts for 91% of the profit associated with cellphone sales. At its height, Blockbuster Video had 9,000 stores worldwide and nearly $6 billion dollars in yearly revenue. The company filed for bankruptcy in 2010 with no remaining Blockbuster stores in America. Blockbuster’s demise was caused in large part by the disruptive ascendance of Netflix which had the foresight not only to anticipate but also to shape the future of video consumption. In a similar fashion, Uber has disrupted the concept of ridesharing and taxi service and has revolutionized the way society views transportation. These companies succeeded not just by predicting the future of their respective industries but by helping to create it. They challenged existing norms and the status quo to push evolution and innovation. When it comes to the delivery of arthritis and  joint replacement care, the medical industry is in desperate need for a challenge to the failing system that is poorly positioned for the future and on a path of unsustainability. To bring about true change may require involvement of entities not currently entrenched in the machinery of medicine. As technology companies begin to realize the potential of the $3 trillion healthcare industry, their greatest opportunity may involve driving change at a macro level.

Proposal

             My proposal is to disrupt arthritis treatment and total joint replacement surgery by creating a network of Arthritis Treatment Centers of Excellence aimed at providing high quality, cost-effective, and comprehensive evaluation and management of hip, knee, and shoulder arthritis. By leveraging existing expertise in establishing effective practice models, integrating technology-based solutions, and committing to high-quality, cost-effective treatment, these Centers would revolutionize arthritis care and create a new standard for arthritis treatment.

The Centers

             Each center would function as a self-contained treatment facility incorporating medical offices and inpatient/outpatient surgical capability with an emphasis on evidence-based best practices. By focusing on a single sub-specialty, the centers will operate in a highly efficient manner, reducing layers of administrative burden, redundancy, and waste. At the same time, referring providers, insurance companies, and patients will view these centers as the pinnacle of comprehensive treatment for arthritic problems. We will strive to eliminate existing inefficiencies and barriers of the current system including poor communication, lack of care coordination, inadequate documentation, lack of patient engagement, and similar shortcomings that erode the quality of care and negatively impact outcomes. By adhering to strict, evidence-based standards and achieving superior outcomes (which will evolve and improve over time through data collection and analysis and use of a joint registry), we will prove the value proposition of these centers to commercial insurance companies, the government, and (most importantly) patients.

Each member of the center from those scheduling patient appointments to OR staff to physicians and physician extenders will go through specialized training to ensure consistency and quality while adhering to the highest standards of care. Centers will have the capacity for both outpatient joint replacement and short stay (1-2 day) inpatient procedures with the goal of minimizing length of stay through rigorous preoperative evaluation and optimization. Patient experience and satisfaction will be paramount throughout the process. The centers will incorporate state-of-the-art technology including smart speakers, tablets, device- and web-based applications, and other methods of telehealth to maintain intimate contact with patients from start to finish. Technology will be leveraged to maintain contact with patients to answer questions, triage problems, reduce ER visits and re-admissions, and reduce the need for expensive post-acute care such as inpatient rehabilitation, skilled nursing facilities, and visiting nurses.

Taking Back Control

             Levels of physician dissatisfaction and burnout continue to increase due to declining reimbursement, increasing administrative burden, the introduction of electronic health records, and rising overhead costs. Increasing government and insurance company regulation coupled with the loss of physician autonomy caused by hospital and health system mergers has led many physicians to consider alternate careers. One of the primary goal of these centers will be to return control back to surgeons and restore the doctor-patient relationship by creating a streamlined system that minimizes time spent on non-clinical tasks and maximizes physicians’ ability to focus on patient care. By returning control of healthcare delivery to physicians, these centers will become a sought-after place to practice specialized arthritis care thereby attracting motivated, high quality surgeons. The smaller, more efficient, and specialized nature of these facilities will also attract various allied professionals including physicians’ assistants, nurse practitioners, clerical staff, nurses, anesthesia staff, etc. who seek to thrive in a well-managed, high efficiency, high quality facility. At the same time, we will focus intently on patient satisfaction by removing barriers to care delivery.

Disruption

             By challenging the existing (and failing) systems currently in place, these centers will be at the forefront of a new paradigm of arthritis care. As with other instances of disruption, our goal will be to predict the future by creating it. The centers will address and seek to solve many of the current failings and shortcomings of arthritis treatment today. We will embrace the concept of price transparency so that patients have a clear sense of the cost of their treatment with concise explanations of billing and costs to reduce patient confusion and frustration. For qualified patients, we will provide lifetime guarantees of implanted devices leveraging the strong survival data of current designs and will take responsibility for complications by providing management free of cost. Doing so will engender trust with patients and make these centers a preferred destination for joint replacement. We will strive to treat all but the sickest, highest risk patients (those who require a tertiary level of perioperative care) to avoid claims of “cherry-picking” or “lemon-dropping” that are often leveled at specialty centers. We will make public and easily accessible robust data on our outcomes, complication rates, costs, and patient satisfaction scores and strive for transparency and quality in all we do. We will establish a joint replacement registry to track outcomes and incorporate technology such as artificial intelligence, deep learning, and neural networks to improve care design and delivery. 

             The way forward in creating a new paradigm of healthcare delivery may very well arise from an entity currently considered an “outsider” in the medical field. Companies such as Haven, Apple, Google, Microsoft and others have begun to realize the tremendous potential that exists in the United States healthcare system to shift the way care is delivered and provide novel approaches to diagnosis and treatment. For a forward thinking company, the willingness to partner directly with high quality, motivated physicians who are committed to solving the current system’s problems represents an opportunity to create a way forward for American medical treatment not beholden to the antiquated approaches of the past.

Conclusion

             We are at a crossroads in the delivery of arthritis care. Success going forward will be predicated on delivering high quality, low-cost, efficient care. While alternative payment models, bundling of care, incentive programs, and other models solve some of the existing problems, they are likely short-term solutions with diminishing returns that further complicate total joint care delivery. The convergence of an aging baby-boomer population, increasing need for arthritis care, and potential inability to meet the coming demand may create a crisis in the treatment of hip and knee disorders. Current systems are ripe for disruption and desperate for a new model of treatment. Our goal is to return a measure of control to physicians and give patients a high quality, efficient, and forward-thinking approach to their care. By creating small, hyper-focused centers, many of the problems facing us in the future can be addressed to create a new way forward.