With increasing numbers of orthopedic procedures moving to ASCs, the relationship between health systems and orthopedic practices is evolving. Collaboration is becoming more important to ensure patients have access to the full spectrum of care, from outpatient settings for certain procedures to traditional hospital settings for more complex and higher-acuity cases.
Becker's Healthcare recently spoke with three experts from the Florida Orthopaedic Institute about the current environment and what steps health systems and orthopedic practice leaders can take to foster true partnerships to yield long-term success for all parties, including patients:
- Andrew Cooper, MD, hip & knee specialist, Vice President
- Michael Doyle, Chief Executive Officer
- Roy Sanders, MD, foot & ankle specialist, President
Orthopedic practices and health systems are looking for alternative care delivery models
Over the years, the nature of hospitals' and health systems' relationships with orthopedic surgeons has changed. "I think it's well understood at this point that it's hard to be a small, private-practice orthopedic surgery group," Dr. Cooper said. "There's the complexity of care, different payment models, like gain sharing, the at-risk model, and the relationship with payers. These factors have made it more challenging for small group practices to endure."
For some orthopedic surgeons, hospital employment is attractive. But that arrangement also has disadvantages. Some find the relationship is too one-sided. As Dr. Sanders noted, "The turnover rate for hospital-employed physicians is quite high."
As surgeons seek autonomy from the hospital, there is growing interest in alternative models where smaller practices can band together. "That can be an attractive option that allows surgeon groups to have autonomy from hospitals and maintain more control," Dr. Cooper said. This shift is appealing in an environment where more and more orthopedic procedures are performed on an outpatient basis.
"We continue to see more cases that have traditionally been performed in an inpatient hospital setting moving to the outpatient setting," Mr. Doyle said. "Momentum is growing as total joints are done on an outpatient basis and surgery centers in more states have the ability to keep patients overnight who require longer recovery times."
Meanwhile, the shift to outpatient procedures will likely present challenges for some health systems. Most are accustomed to serving orthopedic patients in their operating rooms and with their hospital beds. Now, more of that business is moving to ASCs and other outpatient facilities. According to Mr. Doyle, "Revenue and capacity issues will continue to be a concern for health systems."
Collaborative relationships offer a path forward
Some portion of orthopedic cases will always need to be handled in a hospital setting. As a result, community physicians and health systems must collaborate to ensure that patients have access to the full spectrum of care.
"It's problematic if health systems end up hiring their own orthopedic surgeons because they don't want cases moving out of the hospital," Mr. Doyle said. "In the absence of collaboration and transparency, communities often end up with multiple programs that dilute the quality of clinical care."
A better alternative is for health systems and orthopedic practices to engage in open conversations that can lead to win-win partnerships. "There's no sense in keeping secrets and then suddenly all the procedure volume disappears from the hospital," Mr. Doyle said. "Practices should talk with health systems so everyone understands that not all the orthopedic cases will immediately move out of the system. Orthopedic practices must communicate so hospitals can plan. At the same time, hospitals need to engage in direct conversations and not be punitive to physicians."
Dr. Sanders agreed that transparency is essential for collaborative relationships. In addition, the goals of health systems and orthopedic practices must be aligned. In successful partnerships, both parties must bring something to the table. "I think there are ways to partner where everyone wins, including the health system, the orthopedic group and patients," he said. "Hospitals must recognize that cases will migrate to the outpatient setting. It's not just a financial decision. The efficiencies and the patient experience are better and there's less chance that patients will contract a nosocomial infection in an ASC."
At the same time, orthopedic surgeons must be mindful of the issues and constraints facing health systems. According to Dr. Sanders, "Patient care can't be compromised, but that doesn't mean that cost isn't a factor. The simplest illustration I can think of is implant costs. Many surgeons like implants with all the bells and whistles, but that product may not be affordable for the health system."
An orderly transition of orthopedic cases to outpatient facilities can be beneficial for health systems as they develop new programs and look at new opportunities to fill beds.
"I think both parties have to come to the table realizing that they need to work together," Dr. Sanders said. "It may be in a newer facility or a different paradigm. The reality, however, is that the paradigm is shifting and both sides need to work together to serve the best interests of the patient."
Trust and understanding are essential for successful partnerships
Health systems and physicians each have unique concerns. To create a solid foundation for partnerships, trust and respect are required from both sides. "Like any arrangement, trust and understanding will always be the most important features in a relationship between a health system and an orthopedic practice," Dr. Cooper said.
As orthopedic practices evaluate potential health system partners, it's important to look for organizations that have had good relationships with other practices and surgeons in the past. "Are you getting a positive vibe and positive feedback that the health system's relationships are doctor-friendly and doctor-respectful? If the organization seems very one-sided and they don't respect the doctors' input, I think that is a warning sign about future involvement," Dr. Cooper said.
Joint ventures can generate benefits for health systems and orthopedic practices alike
Although a lot of orthopedic procedures are now performed in surgeon-owned ASCs, many centers don't have the facilities required for large cases where patients need to stay overnight. "With the right relationships, opportunities may exist to create joint venture centers to handle these types of cases," Mr. Doyle said. "These would allow hospitals to preserve revenue and enable health systems to provide the right level of care at the right site of service."
Technology may also play a role in joint ventures. New technologies, like robotics, that allow certain types of cases to be handled in the surgery center with greater efficiency and effectiveness have become widely available. However, technology can also be very expensive for a surgery center. "It's going to be very interesting to see how both sides adjust. Will health systems get more aggressive with technology to keep certain cases in the hospital setting? Will technology vendors sell their solutions to surgery centers using different payment models?" Dr. Cooper asked.
Dr. Cooper believes joint partnerships could be the answer to leveraging technology more extensively in outpatient settings. Health systems often have a much better understanding than orthopedic practice leaders of the role of capital and how to finance technology investments in efficient ways. At the same time, the healthcare community recognizes that it's more cost effective and higher quality to do certain orthopedic cases in a surgery center.
Joint ventures work best when there is transparency and the interests of both parties either are aligned or complement each other. "There are ways to enter into joint ventures or other agreements so that what both parties view as a threat can be addressed before there is any movement of cases. Information is key. Having transparent conversations can allay the fears of both parties," Mr. Doyle said.
Conclusion
When health systems and orthopedic groups partner, rather than compete on their own, it improves overall patient care. "In the past, the environment was much more competitive," Dr. Sanders said. "I think now many opportunities exist for health systems and orthopedic practices to work together transparently. With value-based medicine, the opportunities for both sides to win are profound, as long as they don't feel threatened by one another. It's my hope that health systems and orthopedic practices can come together and work it out for the best interest of the patient. It doesn't have to be a zero-sum game."