Drs. Owen O'Neill, Fred Harris on the importance of autonomy, value-based care at Twin Cities Orthopedics

Practice Management

Last year, in the face of industry consolidation, Minneapolis-based Twin Cities Orthopedics established the Infinite Health Collaborative to preserve physicians' autonomy and advance value-based care.

The 35-location group serving communities across Minnesota and Western Wisconsin recently completed its 5,000th prospective 90-day commercial bundle and plans to expand its bundle payment initiatives into sports medicine.

Orthopedic surgeon Owen O'Neill, MD, and neurosurgeon Fred Harris, MD, spoke to Becker's Spine Review about the importance of autonomy for TCO, consolidation in healthcare and the practice's value-based programs in spine and orthopedics.

Question: How important is maintaining autonomy for TCO? 

Dr. Owen O'Neill: We feel that independent physicians and autonomy as physicians is what can lead to value in healthcare, ultimately meaning better care for less money. The i-Health collaborative was developed with other like-minded independent physicians to come into our practice as a partnership. These practices come into our practice on a multispecialty basis so we can start to offer value-based care across our specialty lines. It started with 42 OBGYN physicians joining us and now we have cardiovascular care as well as colorectal surgeons joining this spring. 

Q: Dr. Harris, what prompted your decision to move from a health system to join an independent practice?

Dr. Fred Harris: I joined a hospital system based in northern Minnesota in 2007 out of my residency program and worked there for eight years before moving to Minneapolis and joining another large health system. In the health system environment, I found that surgeon autonomy can easily be lost. I began to feel that I did not have control of things that I felt were necessary for me to be successful and for my practice to grow in the direction I desired. Frankly, I felt that if I was going to succeed or fail, I wanted to be able to do it my way. When it came to staffing, opening clinic locations and even changing clinic templates, I found it more difficult than necessary in the health system environment because there were always multiple layers of leadership review and input required to get these things accomplished. 

Watching TCO physicians and surgeons and the organization during my years of employment in a health system in Minneapolis, I noticed the autonomy they had in the group, how efficient they were and how they all had the opportunity to broaden their horizons through practice growth, patient care and marketing. They had the opportunity to practice at whatever location or hospitals they wanted and to grow their practices as they felt best for their patients. The organization seemed to be growing and moving in the right direction and that is what sparked my interest in moving from health system employment to independent practice. 

Q: What advice do you have for smaller practices that are struggling with rising costs and declining reimbursements? What is the best way for them to maintain their independence and autonomy?

OON: It's a difficult environment out there if you're a small practice. I would suggest that smaller practices around the country look at other practices within the same specialty. There's a lot of infrastructure that's necessary to be successful today. We believe if you can get together with other practices, you can grow and continue to maintain independence, which allows those practices to continue to flourish. 

Q: What is your opinion on private equity breaking into the market?

OON: There has been an influx of private equity investment in the market, but I think entities like that are ultimately taking money out of the system. We don't want to take money out of the system, we want to create better value within the system we have. 

Q: How do you see private equity developing in the market in the next five years? Will it fade away or remain a trend for years to come?

OON: I believe it's probably going to fade away as time goes on. I think private equity looks at practices that haven't fully developed. They look at developing a more vertically integrated practice such as a surgery center and imaging. But ultimately private equity expects a return on their investment and that's taking money out of the healthcare system. We believe that the same things can be done with equity that already exists within the healthcare system. We believe strongly that it's important to partner with hospitals and health systems, all working together to provide that better value for the patient. And I think private equity adds another layer to the healthcare system that we at TCO believe isn't necessary.

Q: Touching on value for the patient, how have value-based programs developed at TCO over the past five years?

OON: TCO has done the most prospective 90-day commercial bundles of any provider in the country. We developed it seven years ago with the goal of creating that value-based care. Our mandate was to create better care for less money. To do that, we developed this program where we've taken 30 percent off the commercial rates for total knee and hip replacements within our marketplace. In our first year we did 11 patients and last year we did 1,700 patients. We just reached our 5,000th prospective commercial bundle — we don't do retrospective bundles where it's just really a cost adjudication. 

Our patient satisfaction has gone up. That's because through this bundle, patients feel like they're getting concierge care — they feel like they're in a higher touch environment. Because you control the bundle per se, that allows us to add things into the bundle that create value to the patient, the surgeon and the system. 

So, we've gone from that 11 patients in year one to 1,700 patients last year. We've saved more than $60 million to the healthcare system in our local market, based on the bundles for knees and hips. We've expanded into shoulders and ankle replacement and are now doing bundles for spinal fusions.

Q: What has your experience been with the spine bundle at TCO, Dr. Harris?

FH: I perform anterior cervical fusions, anterior cervical arthroplasties, lumbar discectomies and lumbar decompressions and fusions at our ambulatory surgery centers. We invested in state of the art neuronavigation systems and spinal equipment that makes surgery in our ASCs more efficient, accurate and safe for the patients. I have found that [bundled payments] have been very efficient and rewarding in ASCs with the right patient selection. The patients that undergo anterior cervical spine surgery usually leave the surgery center and go to our care suites and stay overnight. The lumbar fusion patients usually stay up to two nights in the care suites prior to discharge home. These patients have been very happy with their results from surgery, their experience in the surgery center and their postoperative care in the care suites. My request for spine bundle care in the ASC has significantly increased over the past year. 

Q: What is one key factor to consider when developing a bundled payment program?

OON: Whenever you develop a bundle — whether it's a total hip or knee replacement or a spine bundle — one has to look at technology and devices. It's really important that we ensure an efficient use of those devices and that we work diligently with the vendors to get products that are tried and proven, but that also create value within the system. Also, when developing bundles, it is key to medically optimize patients preoperatively so that medical complications are decreased postoperatively while in the bundle.

Q: What area of expansion will TCO be focusing on this year?

OON: We are continuing to look for like-minded spine and orthopedic groups that focus on that value-based mandate that we feel we have. We're continuing to add practices both in orthopedics and spine on a multispecialty basis. 

Most of our bundling has been in the orthopedic joint replacement and spine space, but now we are expanding bundles into sports medicine. We've recently added Robert LaPrade, MD, from Vail, Colo.-based The Steadman Clinic, who performs very advanced reconstructive surgery, so we'll be adding bundles in that regard. We'll also be adding bundles and value-based care into other specialties that will be joining our practices.

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