What Rothman Orthopaedic's joint replacement strategy gets right

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Rothman Orthopaedic Specialty Hospital in Bensalem, Pa. was ranked as the best hospital in the state for joint replacement, and a key factor to achieving that honor lies in a holistic approach to care, according to Max Courtney, MD.

Dr. Courtney, chief of joint replacement at Philadelphia-based Rothman Orthopaedic Institute, spoke with Becker's about how the group goes the extra mile for joint replacement outcomes and why insurers should recognize the work surgeons do beyond the procedure.

Question: What's been working for the hospital to get this honor?

Dr. Max Courtney: We're honored to be recognized as one of the top joint replacement hospitals. We just want to do the right things for our patients. The biggest thing that I think we can offer at Rothman Orthopaedic Institute is a streamlined, evidence-based approach to joint replacement and rapid recovery protocols. It starts with meeting them in the office. From the time that you have a conversation with a patient for surgery, it's not just about their hip or knee arthritis. We ask about their social situation, where they live, how many flights of stairs they go through and all of their medical history. There are some risk factors that we can help optimize before they get their hip or knee replacement that will give them a better outcome. 

So if a patient's diabetic, we're going to get screening labs to better understand their diabetes. If their blood sugars can be better controlled, we will have them see their primary care doctor beforehand. Are they on medications for rheumatoid arthritis? We will talk with their rheumatologist to make sure we stop it for a cycle in order to lower their infection rate. Are they obese? We have them go to nutrition labs. We have a dietitian on staff, and we work with them to work on weight loss in order to optimize them before joint replacement.

We have a robust nurse navigator program and several full-time nurses that after we sign them up for surgery, they are going to contact and talk with each patient to discuss their needs. Postoperatively most of our patients are able to go home the same day or the next day after surgery, but there are some patients who may benefit from physical therapy at home and a very small subset, might even need to go to a rehab facility afterwards. Additionally, we have nurse navigators to help coordinate what clearances they need. Do they need to see their cardiologist beforehand? Are there patients that have a pacemaker and substantial medical comorbidities? They should be done at our tertiary care academic hospital. Our patients who have better controlled comorbidities can be seen at Rothman Orthopaedic Specialty Hospital.  

Q: What have been some of the financial costs in taking these extra steps and what have been the payoffs besides patient outcomes?

MC: That's been a big sticking point. I serve as the vice chair of the American Association for Hip and Knee Surgeons Advocacy Committee, and I serve on the executive committee of the American Academy of Orthopedic Society's political action committee. It's been a big advocacy push of ours to recognize the amount of work that we're doing to optimize these patients, because right now we do not get paid for it. We pay our nurse navigators out of our pockets — that is not paid through the insurance company. The pre-admission testing or medical doctor can bill for an office visit, but the extra mile that we're going doesn't get compensated through the insurance company. We as a society, not just at Rothman, but orthopedics as a whole has done a much better job. 

When I was a resident 12 years ago, everybody spent three days in the hospital, everybody went to rehab, everybody got a blood transfusion and we don't do that anymore. Because of all of these protocols, the surgery is much safer. Patients can go home. They don't need to go to a rehab facility. They are leaving the same day or the next day. We have lobbied CMS to give us a code called a principal care management code that they approved for our perioperative management of our joint replacement patients. We started to use it this year. But before that, we haven't been able to be compensated for any of that pre-authorization time.

Q: What's the next thing that you're hoping to get from CMS? What's the next big goal?

MC: I think CMS should, should recognize the quality of care that joint replacement is providing. There has been a couple issues where CMS has decreased, not just they decreased every physicians payments, but conversion factor across the board, but they specifically for hip and knee replacement. We took a 5% cut three years ago through the Relative Value Unit Committee, who reviewed our times associated with our surgeries and because patients weren't spending three days in the hospital anymore, they took one of those hospital visits away and they cut our reimbursement for the procedure. We would argue that we're you, we're actually sending people home, and we're saving CMS tons of money by optimizing care, getting people out of the hospital and not sending them to rehab. 


Another issue we have is bundled payments. That's been a hot button topic in orthopedics and the bundled payments for Care Improvement Advanced initiative — which Rothman took part of up until 2020 — was detrimental to orthopedic surgeons. Our practice lost nearly $8 million despite providing this great care, being at one of the top joint replacement hospitals in the country. Because of the methodology associated with the target price calculation, we were being benchmarked on our performance from three to four years prior, which was already fantastic. Medicare kept cutting our bundled payments so we had to drop out of the program. Many other centers across the country had to drop out of Medicare's bundled payment program. So CMS does need to recognize the value that hip and knee replacement care has and then the value that we are providing them by doing cases at ROSH, that's one of the top ranked in the country for joint replacements.

Q: What are some of your top goals this year? What are you looking most forward to?

MC: As a practice, we want to continue to provide despite the economic headwinds of running a practice with inflation, wage costs and CMS decline in reimbursement. We are hoping to continue to provide excellent quality care to our patients. Our goal is to continue to be in the top 10 nationally for readmission rates, complication rates and patient reported outcomes, which we are, and continuing to advocate for our patients. We have several administrative burdens, such as prior authorization from insurance companies, and we talked about the declining reimbursement. So there's some hot button issues that we want to continue to advocate for our patients, both at the state and federal level.

We take pride in our private practice autonomy, but we are still a tertiary care institution. We take pride in caring for everyone. We take on the most complex revision and complex primary hip and knee patients in the Philadelphia area, and we take pride in being able to offer that service to our community.

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