Nikhil N. Verma MD, is a professor and director in the division of sports medicine at Midwest Orthopaedics at Rush in Chicago. Here, he shares his thoughts on outpatient orthopedics.
Note: Responses have been lightly edited for style and clarity.
Question: What changes or opportunities are you expecting to see for outpatient total joints in the coming years?
Dr. Nikhil Verma: Outpatient joint replacement remains the largest upcoming opportunity for improvement in quality of outcomes, patient satisfaction and cost reduction in the orthopedic space. In large part, much of the movement to the outpatient setting is gated by payers, both private and government, adding joint replacement to their outpatient ASC procedures eligible for reimbursement. However, it has been clearly demonstrated that with proper patient selection, these cases can be performed safely and successfully in the outpatient setting. In addition, dedicated orthopedic-specific ASCs can provide very high levels of quality in regards to lowering complications such as infection while improving patient satisfaction with regards to the perioperative experience.
Q: Are there any kind of overarching trends that you're seeing right now in outpatient orthopedics?
NV: Three key trends include:
- Migration of total joints to outpatient facilities limited in large part by government and private payer adoption.
- Continuing refinement of protocols for patient selection and perioperative management for outpatient joint replacement.
- Development of value-based metrics which can assess and demonstrate quality and value after outpatient joint replacement
Q: How do you hope the ASC industry will change in the coming years?
NV: The ASC is the biggest opportunity to improve on value in joint replacement. This includes both the outcomes side as well as the cost side which is clearly lower at an ambulatory facility. Facilities need to embrace change and pursue orthopedic speciality certification while working to develop and refine protocols specific to total joint patients to include monitoring and recording outcomes.
Q: Is there any new technology you're looking forward to on the horizon?
NV: Outside of the standard develops in implants and techniques that continue to evolve over time, the largest opportunity, in my opinion, is harvesting large data and analytics to help maximize outcome with patient treatment. Specifically, if we can identify outliers and provide earlier intervention to minimize the patient with failure of progression after an intervention, or if we can use data to predict patients who are at risk for poor outcomes or our poor candidates for surgery, we can better provide personalized treatment algorithms that provide the best outcome for the patient and the most appropriate use of healthcare dollars.
Q: Do you have any tips or things to know before starting a total joint program?
NV: Learn from those who have experience! Visit a center that has a robust outpatient joint program ongoing. Make sure you have protocols in place for appropriate patient selection, perioperative management and outcomes assessment. The success of an outpatient joint program is determined in large part prior to the patient coming to the operating room. Specifically, patients need to be appropriately selected and the appropriate educational process and resource allocation put in place to maximize success.
Q: Do you think private equity will have an impact on the orthopedic specialty? Why or why not?
NV: In the short term, the obvious advantage to the physician is the ability to monetize the value of the practice with an upfront lump-sum patient. However, what is less clear is the value that PE may bring on the long-term health and function of the practice. Will they offer any strategic advantage? I think for smaller practices, a "roll-up" type model which allows for consolidation of smaller practices into a larger entity, taking advantage of consolidation of overhead and management, and using larger numbers to improve efficiency with large investment practice requirements such as EMR, malpractice and negotiation with payers, along with establishment and growth of ancillary service lines.
For larger, more established practices, the long-term value is unclear, and the giving up a majority control position has unclear implications for future physician recruitment and the long term stability of the practice.