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  • ASCs, technology, consolidation & more: The trends that are saving orthopedics

    ASCs, technology, consolidation & more: The trends that are saving orthopedics

    Ariana Portalatin -  

    The migration of outpatient procedures, consolidation under orthopedic supergroups and innovative technologies were among the top trends surgeons credited with saving the specialty. 

    Insight from 13 surgeons:

    Editor's note: Responses were lightly edited for clarity and length.

    Nicholas Grosso, MD. President and Orthopedic Surgeon for the Centers for Advanced Orthopaedics (Bethesda, Md.): The question of what is "saving" orthopedics depends on your point of view. As a private practice orthopedic surgeon, I feel that orthopedics is being saved by the consolidation of independent private practice groups into large "supergroups." 

    By joining together, these groups can remain viable through the savings realized by the economies of scale, and they can stay competitive by having the resources to build the infrastructure necessary to navigate the rapidly changing healthcare landscape, including transitioning to more value-based payment models. By not allowing themselves to be purchased by a hospital system, or taking private equity investments, they retain the independence necessary to continue to practice the way they see fit without having to answer to outside investors. I also feel supergroups will be able to provide the most cost-efficient care in the market, making them attractive to large, self-insured employers and payers willing to enter into capitated arrangements for their musculoskeletal care. This was the motivation behind the development of the Centers for Advanced Orthopaedics nearly a decade ago. 

    Niranjan Kavadi, MD. Spine Surgeon in Oklahoma City: The most important trend at this time in healthcare saving orthopedics is the transition to outpatient surgical care whenever feasible. Traditionally, open musculoskeletal procedures have been associated with postoperative pain interfering with rehabilitation. Minimally invasive techniques to achieve excellent outcomes are evolving rapidly with an advantage of less surgical morbidity and quicker rehabilitation. Specifically for the spine, endoscopic techniques are appealing. Obviously careful selection of patients who are suitable for outpatient care is essential. Outpatient surgery not only can potentially save the hospital setting resources for sicker patients but also has a positive psychological impact on the patients facilitating rehab and return to daily activities.     

    Stephen Barr, MD. Orthopedic Surgeon at Spectrum Orthopaedics (Portland, Maine): The rapidity of change, the increasingly complex world of insurance, medical regulation, loss of physician independence, all combine in a flanking attempt to drive a wedge between the doctor-patient relationship. This, I feel, will be the key saving trend in orthopedics. I try my best to get in tight with the doctor-patient relationship, a place I feel most comfortable and gain the most satisfaction from on any given day in my practice as an orthopedic surgeon. In the words of one of my orthopedic professors, Bill MacAusland, MD, past president of the American Academy of Orthopedic Surgeons, "When the physician bears the patient's pain then will medicine its fainting hope sustain!"

    Davis Hurley, MD. CEO of Orthopedic Centers of Colorado (Denver): For many, the pandemic has been a wake-up call for an improved quality of life and being in your best shape for the future. Young and old patients look to orthopedic surgeons for fitness and injury recovery optimization in the here and now. Orthopedics can use a long-term perspective and a back-to-action-now mentality to facilitate musculoskeletal health for today and a more active future.

    Orthopedic surgeons are well-positioned to create patient, community and business benefits with their ability to bend the cost curve. Site of service savings and a willingness to advance value-based care initiatives are ideally suited to the orthopedic surgeons' choices for patient care.

    One cannot lose sight of the professionalism required of being a physician and surgeon. Patients count on surgeons, and we must have a seat at the table to advocate for our patients and the future of our specialty. Unfortunately, many influences and competing interests undermine our status as a knowledgeable and skilled profession. Focusing on quality patient outcomes, a value-based perspective and technological advancements based on a bedrock of patient safety will save our specialty.

    Matthew Barber, MD. Orthopedic Surgeon at Springhill Medical Center (Mobile, Ala.):

    1. Transition to care in ASCs for more cases, particularly total joints and spine. This has helped to streamline care, produce better patient experiences, reduce costs and facilitate alternative payment models.

    2. Alternative payment models. This one is early and will take some time to mature. However, as this market develops it will help to realign things to more patient-centered care and will help to preserve surgeon autonomy. This is a space that is evolving due to oppressive insurance costs and bureaucratic red tape. It includes direct care (cash pay), medishares, bundled payments, employer contracting, and population management for musculoskeletal care. It is unlikely that any of these models will completely dominate, but they will create an ecosystem of options that gives patients more choices and allows participating providers to remain independent. As these options open up, it may reverse some of the recent flow of private practice surgeons into employed roles.

    3. The internet. That sounds stupid to say, but the democratization of information will help to save orthopedics.

    - Patients can learn about surgeons and procedures.

    - Patients can shop for options that fit their needs clinically, financially and logistically.

    - Social media allows healthcare consumers to vet their providers almost instantly.

    - Surgeons can cross talk with an international community of their peers in real time.

    - Open access journals like The Journal of Orthopaedic Experience and Innovation help to rapidly spread concepts that are significant to surgeons that insider networks at traditional journals stifled.

    Deepak Reddy, MD. Orthopedic Surgeon at South Bend (Ind.) Orthopaedic Associates: As an orthopedic spine surgeon I'm constantly amazed at our evolution over the past 30 years. Certain subsets of medicine have remained rather stagnant over time, fundamentally doing the same thing today that surgeons did 20 years ago. Spine, however, has been a hotbed of innovation. The progression of minimally invasive surgery aided by novel less-invasive approaches, enabling technology, hardware solutions and biologic advances continues to push spine surgery forward. 

    Even today, how I solve spine problems is dramatically different from where I was six years ago. Advances in this regard have fueled the transition to outpatient spine care in the ASC and continue to drive better patient outcomes while reducing the morbidity of traditional spine surgery. Not only is this trend saving orthopedic spine, it's resulting in better patient care, tearing down the stigma of spine surgery's mixed outcomes with advances in minimally invasive surgery and technology. I believe we will see this trend continue as enabling technology advances and big data analytics permeate into the world of spine surgery. Enabling technology will likely continue to drive MIS allowing faster, less invasive approaches and transition toward aiding surgeons with the decompression as well as the hardware placement. Big data analytics will push forward with the goal of reducing the variability of diagnosis and treatment algorithms. Today, five spine surgeons approach the same problem in five different ways. In the future we may be able to use historic data to drive decision making and reduce the variability of treatment and variability of outcomes. 

    Lastly, innovations in post operative pain management with the increasing usage of multimodal anesthesia and enhanced recovery after surgery protocols has further facilitated outpatient and less invasive care with a lower reliance on opioids. Further innovations in this space will continue to offer spine surgery to patients with a safer and more predictable postoperative course. There are a number of interesting innovations in the space of neural stimulation currently being worked on, which may further benefit our patients. I'm excited to see what the next 10 years of practice looks like as we continue this evolution that is currently saving spine surgery and essential to its future. 

    Kern Singh, MD. Co-Director of the Minimally Invasive Spine Institute of Midwest Orthopedics at Rush (Chicago): The movement of spine cases to the ambulatory setting will continue to play an important role in the evolution of spine surgery. By utilizing ASCs to match surgical settings with patient and procedural risk, surgeons are able to achieve considerable cost savings while maintaining greater autonomy over patient care and practice.

    From a financial perspective, the ASC delivers the clear benefit of avoiding the expenses associated with inpatient admission to the hospital, affording insurance companies and providers considerable savings. In addition, the ASC increases the financial interests of physician owners, providing a clear incentive to save on operative costs via process standardization, which may in turn facilitate a favorable reduction in the price of surgical implants.  

    Along that concept of physician interest, the ASC may promote increased surgeon autonomy in their practice. As large hospital systems continue to expand through acquisition of private groups, the autonomy of the surgeon in the hospital faces increasing resistance. Surgeon ownership of outpatient surgical centers provides an avenue for enterprising physicians to take ownership of their patient care and collections with less administrative resistance.

    Michael Wood, MD. Orthopedic Surgeon at Mayo Clinic (Rochester, Minn.): There are at least four trends that will have a positive impact on the specialty of orthopedics over the next decade:

    1. The age-related demographic trend in the U.S. as well as worldwide. This has been a relentless trend over the last century but is expected to continue unabated. In 2019, there were 54.1 million Americans over the age of 65, and by 2040 this number is projected to be 80.8 million. In general, people over the age of 65 consume four-fold more healthcare per capita than the population under the age of 65, and this can be expected to apply to orthopedic care as well.

    2. Orthopedic residency applicants are increasingly more accomplished in terms of academics (DePasse, et.al., JBBS, 2016). This is reflected in the higher USMLE scores as well as the greater number of publications, abstracts and presentations from applicants over the last 10 years.

    3. The breadth and depth of what is considered orthopedic surgery is expanding as a result of advances in biology and engineering. This includes the discovery of tissue substitutes, materials advances and implant designs.

    4. Virtual care has recently become a practical reality as a result of the COVID-19 pandemic challenges to in-person care. Although it is uncertain if the regulatory obstacles to virtual care that have been relaxed as a result of temporary COVID-19 policies will be continued as permanent, virtual care has the potential to expand access to a greater population for orthopedic care.

    Earl Kilbride, MD. Orthopedic surgeon at Austin (Texas) Orthopedic Institute: In general, our aging population is much more active than ever before. Couple an aging population with one trying to remain active and orthopedics is actually primed for a curve where the patients outnumber the providers. This is a good problem to have as a provider.

    From a business point of view, two things are contributing to a business model favorable for orthopedic surgeons. First and foremost, the aging patient population is staying active. This leads to an overall increase in the number of surgical candidates. Many, if not most, elective orthopedic procedures can be done as outpatient. The inpatient facilities have now come onboard and are extremely interested in this shift in care. New partnerships will help the orthopedic physician collect on the facility as well. Essentially, combining a bigger denominator of patients with ability to own shares in a facility can help offset the declining reimbursements.

    Andrew Wickline, MD. Orthopedic surgeon at Mohawk Valley Health System (Utica, N.Y.):

    1.  Shift to outpatient and physician ownership of ASCs.

    2.  Interest from employers for carve-outs for specific procedures, which help reduce the cost that the commercial payers extract from the employer (direct-to-employer model).

    3.  Dr. Ira Kirschenbaum's open access digital orthopedics journal, [The Journal of Orthopaedic Experience and Innovation]. This is a major disruptor of a billion dollar industry that quite frankly stifles innovation.

    4.  Marty Nichols' team that is working on developing an orthopedic bank.

    5.  Surgeons with the guts to drop Medicare and commercial payers.

    6.  Transparent pricing models.

    7.  Small- to medium-size orthopedic companies that are still nimble enough to react quickly to market demands and meet deadlines on time or ahead of time.

    8.  The social media surgeons who spend considerable amounts of time identifying problems within the system and pointing them out for non-medical readers.

     9.  Surgeons who take ownership of the issues that patients struggle with and create meaningful solutions.

    Gary Brock, MD. Orthopedic surgeon at Texas Orthopedic Hospital (Houston): I believe the things saving orthopedics are:

    1. The best and brightest medical students are still applying for orthopedic residency programs.

    2. Our leadership has been very proactive in maintaining and encouraging excellence and respect within our profession. These programs include training opportunities around the globe and increased efforts to encourage gender and cultural diversity.  

    3. It remains a cost-effective specialty. Almost every family encounters a need for orthopedic care. Our orthopedic specialists enable people to return to activities they enjoy frequently, including an ability to return to work. Improved quality of life measurements are a reasonable expectation of orthopedic care. 

    4. It's still fun! 

    Harvinder Sandhu, MD. Spine surgeon at Hospital for Special Surgery (New York City)

    1. The shift to ambulatory surgery for many traditionally inpatient orthopedic procedures, such as spinal fusion surgery and knee and hip arthroplasty, is a trend saving orthopedics. The growth in ASCs that can service these procedures has helped reduce cost of care and has improved access to care in many communities

    2. The use of advanced technology such as robotics, augmented reality navigation and better endoscopic imaging has had a dramatic effect on patient safety and ultimately will increase the number of patients that can be indicated for musculoskeletal surgery.

    Scott Boden, MD. Director of the Emory Orthopaedics & Spine Center (Atlanta): Orthopedics will remain a highly valued specialty for the following reasons:

    1. Orthopedic operations have the potential to give patients their lives back in a very measurable way.

    2. The aging population and expectations of mobility and activity in older people will continue to increase the demand for orthopedic services.

    3. Continued advancements in technology will enable better treatment of existing problems and new treatments for problems previously considered untreatable. This evolution in biologics and personalized medicine will further expand the menu of orthopedic services in the coming years.

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