Outpatient joint replacements to 'skyrocket over next 10 years,' says Dr. Richard Berger

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The Western Society of Engineers recently recognized orthopedic surgeon Richard Berger, MD, with the 2020 Washington Award for his contributions to joint replacement.

Dr. Berger, of Midwest Orthopaedics at Rush in Chicago, is the 102nd recipient of the award, following in the footsteps of Henry Ford, Orville Wright and Neil Armstrong.

Here, he discusses the rise of outpatient total joint replacement, robotic-assisted surgery in orthopedics and the increasing trend of bundled payments.

Note: Responses are lightly edited for style and clarity.

Question: Congratulations on the 2020 Washington Award. What does this award mean for you? What are your future goals?

Dr. Richard Berger: It's a great honor to receive such a prestigious award and humbling to look at the list of prior recipients. While I'm not sure I'm worthy of such an award, I am grateful that the committee recognized how surgeon-engineers like me are helping improve the world. Using my MIT mechanical engineering degree, I've designed hundreds of instruments for minimally invasive hip and knee replacements. I pioneered minimally invasive joint replacement surgery, which involves cutting less muscle, tendons and ligaments. About 19 years ago, I began performing these surgeries in an outpatient setting. These advances help reduce trauma and allow for a more complete and faster recovery, better functionality and less postoperative pain. I have performed more than 20,000 minimally invasive hip and knee replacement surgeries, 11,000 of which were on an outpatient basis.

I've been able to use my engineering background to design new hip and knee implants, which function better and last longer than previous ones. I am most proud of the gender knee implant designed for women, who constitute two thirds of all knee replacements in the U.S. In addition, I recently developed a new hip implant that maximizes the plastic thickness by minimizing the metal thickness. The thin and flexible metal more closely matches the surrounding bone that results in bone preservation. The plastic thickness increases the longevity of the implant.

Q: What innovations are you most proud of? What are you currently working on?

RB: Currently, I'm developing a new hip stem system that more closely fits the bone shapes of all patients. I've noticed that customer service has really slipped over the years in this country, which is why I made it a priority in my practice, where we've developed a high-touch, personalized concierge practice. We want our patients to have a great experience, not just during the surgery, but through the entire process — from when they call for an appointment to when they return to work and daily activities. Our designated staff members greet patients when they arrive for consultations, we offer snacks and water during patient visits and provide an extensive and mandatory preoperative teaching program for patients and their caregivers. Our nurses continue to stay in close contact with patients after they return home, during their physical therapy and until they come back to clinic for follow-up visits.

Q: How do you see outpatient hip and knee replacements developing over the next five years?

RB: It has been remarkable to see the evolution of outpatient surgery since I first developed it 19 years ago. Other surgeons questioned if it was appropriate to send a patient home after day surgery. Today, many of them are adopting my model. Research shows that joint replacement patients who recover in their home are just as happy — if not happier — than those who recover in the hospital. In addition, studies reveal the complication and readmission rates for these patients are lower in an outpatient setting. Most of my patients prefer being home where they recover faster, as opposed to being in a hospital.

In the next few years, we're going to see an explosion of hip and knee replacements in the outpatient setting. Everyone is aligned for this to happen. The patients want it, the surgery centers are here to perform it, and it saves money for payers so they are also behind it. Lastly, Medicare has been covering outpatient joint replacements performed in hospitals. However, this year Medicare sanctioned outpatient knee replacements to be performed at ASCs. It's expected that hip replacements should follow within the next year. Currently, 76 percent of my patients leave within a few hours after surgery. This number could be even higher if we had more resources dedicated to outpatient surgery. I think this is the direction that medicine is heading and I predict the number of outpatient joint replacements to skyrocket over the next 10 years.

Q: How do you see robotic-assisted surgery progressing in total joint replacement?

RB: Currently, computer-assisted surgery is in its infancy; it is not very accurate. In addition, it is expensive and time consuming. Based on its inaccuracy, it is really only helpful for inexperienced surgeons. For skilful and competent surgeons, robotic surgery may lead to less consistent results. Particularly for knee replacements, robotic surgery helps a surgeon make bone cuts, however, a knee replacement is a soft tissue balancing operation. Therefore, getting the bone cut right is the easy part. Unfortunately, the robot doesn't help with the soft tissue balancing, which takes training and experience. 

Although it doesn't happen often, a poorly balanced knee is the primary reason that patients are unhappy after their knee replacements. If anything, the robot gives surgeons a false impression that all they need to do is get the bone cut right and the knee will be fine. This is why there can be complications and poor results from some surgeons who use the current generation of robots for joint replacement. I hope robotic surgery improves over the next decade so the outcomes of using this technique will improve.  

Q: Have you implemented bundled payment programs for total joint replacements at Rush? How do you see value-based care developing in this space?

RB: While we've not yet adopted bundled payment programs at Rush, I think this concept makes sense in our current environment. Physicians typically account for about 10 percent of healthcare costs, yet they are in the driver seat to control the other 90 percent of costs for patients. Therefore, financially incentivizing the physician to help oversee the quality and costs involved not only makes sense, but is better for patient care. We as physicians should be the ones deciding what is best for each patient; it is a better paradigm then having an administrator or bureaucrat deny or guide healthcare. I believe this will continue and increase over the next few years.

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