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POSTED November 17, 2017

Buzzword Breakdown: "Patient Engagement"

The healthcare industry is facing a time of transition. In any industry, shifts in business models, modes of communication and availability of options lead to changes in consumer behavior, and health care is no different. The consumers of healthcare, once compliant patients, are now key players in their choice and plan of care. Enter: Patient Engagement

What does ‘Patient Engagement’ really mean?

Patients spend most of their time outside the hospital, out in the world, living their lives. Their behavior when they’re on their own will determine how healthy they are.

So, in order to successfully keep patients healthy, it’s important to support them in understanding and participating in their care. Patient engagement is about empowering patients to better take care of themselves.

Why do I keep hearing about it?

The shift towards bundled payment and value-based care has led administrators to focus on increasing efficiency (i.e. reduce costs) while maintaining, and hopefully improving, patient outcomes. This evolution has led to a focus on decreasing hospital stays and face-to-face patient appointments. This means that even more of a patient’s recovery is happening at home. While in many ways, this is good for efficiency and patient comfort and safety, clinicians need better ways to stay connected to their patients as they heal outside the hospital. Without patient engagement and support, good surgeries can result in readmission, suboptimal outcomes and low patient satisfaction.

But if we give patients direct communication, education and documentation at their fingertips, we activate the engagement between clinician-patient partnership. This allows both patients and doctors to regain control over health outcomes

By supporting the patient in becoming a lead player in their care, the entire team can become more efficient and cost-effective. And, as research shows, more engaged patients tend to have a greater commitment to care and personal health. They are therefore more likely to engage in preventative or postoperative treatment and healthy behavior, ultimately leading to more successful patient outcomes.

What does “patient engagement” mean for the future?

Okay. So we know that patient engagement is an asset. But how do you do it well? How do you measure it?

First step is to breakdown the broad term “patient engagement” into actionable metrics. Defining and implementing metrics allows providers access the information you’d have in the hospital, or in this case, information necessary to keeping patients from readmittance to the hospital.

Scalable and measurable strategies  for engaging patients include technology. Technology allows for the necessary level of patient mobility and accessibility, while scaling the work of patient navigators. With the right platforms, organizations can determine what metrics define engagement for them and study the impacts of their efforts in order to create best practices.

Patient Engagement technology is the the golden ticket through the new medical frontier. It can bring care to patients fingertips, so that providers can increase efficiency without sacrificing quality.


POSTED November 14, 2017

Research Showing Efficacy of Home Recovery is AAHKS 2017 Poster Winner

Meredith Crizer is a joint Research Fellow at The Rothman Institute.

While a large majority of orthopaedic centers still refer patients for formal supervised PT following total knee arthroplasty, there has been growing interest in effectively providing home-based rehabilitation without the need for professional supervision. This likely reflects uncertainty as to the benefit of utilizing such a costly ancillary service, which accounted for $468 million in Medicare costs following primary TKA in 2009, and patient preference for performing rehabilitation in the comfort and convenience of their own home.

The Research Team at the Rothman Institute completed a prospective randomized control trial which questioned the role of formal physical therapy after a total knee replacement by comparing patients among three different groups. The first completed formal outpatient physiotherapy (OPT) sessions, the second used a web-based physiotherapy (Web PT), Force Therapeutics, to complete an unsupervised home exercise program, and the third group was given paper-based physiotherapy (Paper PT) to complete the same program.

The primary outcome assessed patients passive knee flexion at baseline, 4 weeks, and 6 months postoperatively. Ultimately we found there was no difference between patients going to outpatient PT compared to patients completing exercises programs on their own.

Formal PT sessions have been considered a necessary component of postoperative rehabilitation and care following a total joint replacement. The results of our study disrupt this assumption by finding that unsupervised exercises programs are an effective strategy for restoring patients’ functional outcomes. We were prepared for a big reaction to this study, and were happy to find it was a positive one. I had the opportunity to present the study at the Annual Meeting of the Eastern Orthopaedic Association (EOA) and it was the Primary Knee poster winner at AAHKS.

Meredith was featured in our EOA wrap-up video discussing her experience presenting the study. 

Receiving recognition at AAHKS validates our work. It increases public exposure to this topic, and helps refute current beliefs surrounding formal PT. As this topic continues to garner recognition, skepticism surrounding unsupervised home exercise programs will dissipate.

This is in line with healthcare’s movement towards more cost-efficient care. Formal PT services are expensive for providers and patients alike. For Providers the average cost of traditional formal PT sessions after TKA is roughly $2,500 per case, while the average cost of these home based exercises programs is less than $100 per case. The implementation of home exercise programs would create substantial costs savings within bundle payments. Increased utilization of technology may also improve coordination during the episode of care.

Similar to long hospital stays or bed rest, formal PT has been considered a must thus far. However, the findings of this study in particular has questioned its effectiveness. Research like this study will change the way providers routinely prescribe formal therapy and give patients greater autonomy over their recovery.

**This study is pending publication


POSTED November 9, 2017

AAHKS Wrap Up: The Era of Healthcare Technology Has Arrived

Check out our wrap-up video with Dr. Richard Iorio here

Innovative technology leading the trend towards evidence-based solutions within the value-based landscape was a central topic at AAHKS 2017. Research showing the clinical and financial benefits of digital programs are snowballing, which is increasing and broadening interest.

“I think healthtech dominated the meeting,” said Dr. Richard Iorio, a presenter at the conference. “Many of the pre-meeting symposia were dedicated to health tech applications and several of the papers that were presented were first iterations of health tech applications on clinical care.”

These studies found positive correlations with both patient outcomes and cost efficiencies. A valuable indicator as health systems across the country work to lower cost of care deliver while maintaining outcomes. “This,” according to Dr. Jess Lonner, Principal Investigator of a multi-center, technology-based study, “was clearly an opportunity for us to standardize care in a less expensive way.”

As Dr. Iorio points out, “[Care delivery] is a huge cost item for CMS and for the country. We’re doing 1.2 Million lower extremity total joints a year. We need to deliver that care in a more efficient and cost effective manner, and I think technology is the way to do that.”

Dr. Davidovitch introduced the term “EPRA”, or Electronic Patient Rehabilitation Application while presenting a paper called “Home Health Services are not Required Following Total Hip Arthroplasty.” According to the study summary in the program, the study “comparatively evaluated patients receiving EPRA and EPRA-HHS [home health services] demonstrating that there was no difference in PRO scores. Thus it may be assumed that both methods of postoperative rehabilitation are equivalent in terms of clinical outcomes and that HHS may be a redundant service.” This has huge implications for the future of orthopedic care delivery.

Dr. Iorio expects a wave of health tech adoption. “Now that larger more academic institutions are getting on board, and are then publishing that data giving it veracity and academic gravitas,” he said. “I think it’ll be more widely accepted as something that is not only interesting, but essential to deliver care in an efficient manner.”


POSTED October 30, 2017

Managing Patients’ Expectations to Improve Satisfaction

In today’s competitive joint replacement market, healthcare providers are actively identifying and collecting measures of surgical quality. In addition to the traditional quality indicators, such as length of hospital stay and rate of complications and readmissions, more providers are beginning to focus on patient satisfaction. Being one of the most heavily weighted measures used by the CMS to evaluate hospitals and adjust their reimbursement models, patient satisfaction has become a growing priority for hospitals in the US.

A number of studies have recently demonstrated that patients’ expectations may be a key factor in determining postoperative satisfaction. While studies vary in their methods and their definitions of patient expectation and satisfaction, there is general indication that expectation may have an even more significant impact on patient satisfaction than objective levels of function.

Koenen et al. and Noble et al. have highlighted the wide prevalence of unrealistically high expectations among joint replacement patients and the association between the fulfillment of preoperative expectations and postoperative satisfaction. Similarly, Mancuso et al. have shown that patients with higher expectations of recovery, especially in regard to resuming sports activities such as running and hiking, reported greater dissatisfaction compared to those with lower expectations. These results are consistent with our human tendency to be disappointed when our expectations are not met.

Given the high volume of unrealistic expectations in total joint replacement patients, it is important to educate them on what is realistic. Although there isn’t an established gold standard in helping patients set achievable recovery goals, there are few practices that were shown to be effective. According to Elwyn et al., employing two-way communication is key. Traditionally, physicians have simply provided information to the patient - This one-way communication may cause patients to set unrealistically high expectations as most lack the necessary background clinical knowledge. Therefore, it is crucial to establish bi-directional communications and confirm how much the patients know about their procedure and their recovery plan. Also, it is crucial to review all aspects of the recovery plan with patients’ care partner during the pre-operative visit.

Further investigating on the pattern of patients’ recovery expectations will allow physicians and hospitals to improve their patient education preoperatively, better manage expectations and anxieties and ultimately improve patient satisfaction.


POSTED October 25, 2017

ICJR Transatlantic Wrap Up: Value-Based Payment is Here to Stay

At the 2017 ICJR Transatlantic Orthopaedic Congress last week our CEO, Bronwyn Spira sat on a panel discussing the inevitable shift towards value-based care and the role of technology enabling the transition.

Bronwyn asked the crowd of 50 attendees who was using technology in their methods of care, and only three people raised their hands. This is proof that there is vast amounts of growth that must occur to fit the new healthcare landscape in which we now find ourselves.

Dr. Richard Iorio, Chief of Joint Reconstruction, a fellow panelist, is no stranger to the massive impact alternative payment models are having on the way we think of delivering healthcare. Dr. Iorio and colleagues Dr. Joseph Bosco and Lorraine Hutzler are part of the Value Based Healthcare Consortium (VBHC), a network focusing on and developing best practices across the orthopedic field.

CMS knows that value-based payment is saving “18% per episode and they can’t turn away from that. Bundled payments are here to stay,” Dr. Iorio said. This fact alone is impossible to ignore. So, whether or not you’re operating within a bundle, the question should be, how do we prepare for this shift to value?

This brings us to our first takeaway -- activate your patients. Patients want to get better. Often times, lack of knowledge and access to care limits progress. But once engaged, patients have the ability to govern their own recovery.

How much can we decrease costs and improve efficiency without sacrificing outcomes? The panel mutually agreed that standardization is key, and the more standardized in a pathway, the better the cost:outcome ratio.

And lastly, as fellow panelist Dr. William Long said, “We need to get patients out of the hospital and back to walking around New York. People die in hospitals, not walking down the sidewalk of New York City.”

Getting patients home is not only safer, but it is where they feel most comfortable and are most likely to become active in their own care. And when patients are equipped with the proper tools to take an active role in their recovery, we’re seeing equivalent outcomes reached at a much lower cost, with higher levels of patient satisfaction.

Success in this new paradigm will only be possible if we think of technology, not as the solution, but as the vehicle for recovery. Despite some physician’s reluctance to utilize technology, the fact of the matter is we’re in a world where physicians are scored by the quality of outcomes, not necessarily the surgery itself. And as Dr. Iorio pointed out, “the data from newly implemented outcomes technology will show shortcomings in your service line that usually aren’t too difficult to fix with available tools.”

If providers can’t communicate what they want from patients in real time, the system doesn’t work efficiently. Patients want to have a dialogue about their care. The little device that you carry around in your hand will power the revolution of value-based care.

As Bronwyn said, “The train is leaving the station, you either have to get on, or get left behind.

Check out our video wrap up of the conference here!


POSTED October 20, 2017

How to Build a Value-Based Patient-Provider Relationship

With risk-based programs in the works or on the horizon, providers are looking for ways to make their care pathways more valuable -- by reducing unnecessary care, while improving outcomes. This makes interactions with patients during in-person care more important --  as patient engagement and adherence after those brief face to face interactions are critical.

According to research by Emanuel & Emanuel, there are 4 styles of patient-provider relationships built around the degree of patient autonomy. Traditionally, patient-provider relationships are paternalistic, meaning the provider gives the patient instructions based on their medical knowledge and opinion, and the patient listens and generally adheres to the word of the provider. In this type of relationship, the patient has little voice or control, and the physician is seen as a guardian. Paternalistic patient-provider relationships often lead to treatment adherence, but because there is no room for patients’ personal preferences and values or ownership, patients report lower satisfaction levels with their care.

Interpretive relationships involve the physician acting as a counselor. In this type of relationship, the physician gives medical advice after exploring and taking into consideration the patient’s values. They review options with the patient based on those values and support the patient in selecting the best option for their unique situation.

Deliberative relationships are similar to interpretive relationships, in that the physician gives advice based on the values of the patient. Unlike interpretive relationships, in deliberative relationships, physicians carefully select what information to share with the patient in order to guide patients towards what the physician sees as the right treatment option.

Both Interpretive and Deliberative relationships require increased patient-provider interaction, which makes these communication styles unscalable in the current atmosphere without intervention (i.e. technology/ generated engagement). In today’s healthcare system, providers are not able to spend the necessary time with each patient to understand each individual's context and values. As a result, the responsibility is on the patient to seek out health care that aligns with their values. Healthcare companies have responded to this trend by focusing on the value they can provide to the patient, and how they can market to the patient as a consumer and healthcare as a commodity like any other.  

Informative or Consumerist relationships are much more scalable. They are the opposite of paternalistic care. In this type of relationship, the provider is seen as the holder of information -- the patient decides what they will do with it. The provider informs the patient of the available options, and the consumer independently selects their choice.

These types of the relationships are experiencing a surge at the moment, which makes sense. Patients are more financially at the center of care than they have been in the past, and activated patients have better outcomes. Partnering with patients is a win-win. Providers who are moving away from paternalistic relationships, and giving their patients the tools and education they need to successfully make their own choices, are leading the pack when it comes to patient satisfaction and outcomes.

A video version of this blog can be found here, check it out! 


POSTED September 7, 2017

Metrics for Evidence-Based Practice is a Must

By now, it’s easy to see that there are health-related concerns that demand our full attention. Under traditional fee for service pathways, hospitals are incentivized to charge as much as possible, hiking up the averages used to define bundled pricing -- believed to be the benchmark of affordable care.


As we enter a value-based landscape, variation in episode costs can be $80,000+. Although patient variability is certainly a factor, serviceline variation is prevalent across the board. The national standard deviation for TJA procedures operating under the CJR payment model is $10,582 -- meaning, removing the vast majority of outliers, costs still differ by roughly $20,000. Patient satisfaction and outcomes also deviate from the theoretical procedural mean. By tracking patient reported pain levels 30 days post-op, we are able to visualize how varying surgeon practices yield varying outcomes.




Through the use of high level business intelligence -- clear data leading to powerful, repeatable solutions -- efficient entities (no matter the industry) operate with little to no variability. Best practices form when a system is explained with precise correlation between function and outcome. One way of doing this is recognizing consistent internal performers and observing their methods. This begs the ultimate question, how can we decisively measure and compare outcomes?


Healthcare is finally arriving at a place other industries have been for years. It’s not that hospitals and other health systems aren’t collecting data (they are). The concern is that coordinated care is extremely complicated and, for the most part, data is not clear enough to turn suggested changes into completed actions.


Force is tackling the issue by presenting stakeholders -- physicians included -- a clearcut dashboard where each surgeon is appraised and recognized based on costs, patient outcomes and variation among other factors. It’s a solution to the overflow of raw and unusable data that many hospitals face. Transparent, usable data are simply a way to proceed with intelligent decision-making in an efficient manner. With enough data collected, sorted and made transparent, there will be a shift to appropriate standardization of pathways.


For example, outpatient procedures are becoming more common and patients are routinely spending even less time in the hospital with physicians and their care teams. These methods, although thus far proven to reduce costs while sustaining positive outcomes, can only be done with continuous data collection and organization. As we delve into alternative post-acute practices, repeatable solutions and detailed insight within extensive patient populations become even more valuable.


"Physicians are driven by outcomes, research and evidence. In order to create a culture of continuous improvement, data and benchmarking are critical,” commented Dr. Richard Iorio. “Leveraging trusted and transparent physician dashboards that include quality, cost and patient satisfaction metrics is a key pillar of success in the value-based world we're entering."


POSTED July 19, 2017

Getting Ready for the CMS Proposal for Outpatient Joint Replacement

What's going on?

Last Thursday, July 13th, CMS released a proposal that will allow Medicare to reimburse for total knee replacement procedures in an outpatient setting (currently Total Knee Replacement is on the inpatient-only list). If the proposal is finalized, starting January 2018, Medicare will pay for total knee replacements (total hip replacements currently open for public comment) in Ambulatory Surgical Centers (ASCs).


Why is this happening?

Outpatient Medicare coverage should not come as a surprise. In July 2016, CMS submitted a request for public comment to remove TKA’s from its inpatient-only list. Since being added to the list in 2000, developments in Arthroplasty procedures and postoperative care have dramatically reduced complications and variability, including average length of stay from 4.6 days to just 2.8 days in 2016. In many leading centers around the country (many of whom are Force clients), same-day or next-day discharge has become the norm.



What impact will it have?

The implementation of this proposal will disrupt the market by raising the level of competition between facilities by further fragmenting the market, and putting downward pressure on costs for an entire episode of care (outpatient fees are 25-40% cheaper than inpatient). Sg2 healthcare analytics and consulting estimates 52% of primary knee replacements will be performed in an outpatient setting by 2026, likely to significantly reduce overall spending on TKA episodes.


A common concern expressed by many is the effect the proposal might have on existing CMS payment methods – CJR and BPCI. After stressing so much importance on bundled care in inpatient settings, does it make sense for CMS to now drive volume out of the hospital? Bundles depend largely on target prices based on historical costs. Since outpatient procedures generally show improved efficiency and cost reduction, target pricing adjustment is likely – otherwise, do not expect substantial changes in bundled payment models.



What are stakeholders likely to do about it?

In an industry where players are historically reluctant to change, there will most likely be initial resistance to the proposal. However, as the probable becomes inevitable, surgeons who perform a high-volume of TKA procedures will have broader alignment alternatives – hospitals and ASC’s. Providers will act quickly and decisively to preserve TJA profit centers and physician relationships by discussing co-management and employment opportunities, while also improving physician experience.


Without proper incentives, surgeons will happily depart from hospital settings to pursue investment in ASC’s. It’s no surprise, with Dr. Tom Price (Orthopaedic Surgeon) at the helm of CMS, that this proposal gives more control to physicians. Now more than ever, it is essential to look towards ways to improve physician experience by any means necessary. If hospitals choose to forgo formal ways of aligning with surgeons, they must be open to adding more flexibility, better facilities, and superior technology to their system of care.


POSTED June 26, 2017

Bundled Payments Aren’t Going Anywhere -- The Time to Transition is Now

As of March 2017, CMS announced they are postponing the initialization and expansion of several mandatory bundled payment methods, including the extension of the CJR model -- already applied to 67 U.S. regions -- and initiatives for hip fractures (SHFFT) and cardiac care. In the meantime, these delays should not deter health centers from consolidating systems and ideas to scale -- the time to transition is now!


Let us first clear up any doubt about the future of bundled payment cast by the Trump administration’s attempts to repeal the ACA. The American Journal of Managed Care states, “if the coverage elements of the Affordable Care Act (ACA) are repealed, payment reform would move forward under the Trump administration, in part because Republicans voted overwhelmingly with Democrats for the Medicare Access and CHIP Reauthorization Act (MACRA).” Yes, the delays are because of an executive order halting new rules, and yes, HHS Secretary, Tom Price, is strongly against mandatory payment methods, but there is still overwhelming popularity of healthcare payment reform and it starts with the CMS initiatives.


The real reason for delays

Healthcare reform does not happen overnight. According to the interim rule set in place, CMS, and other participating organizations need time to “modify the policy if modifications are warranted, and to ensure that in such a case participants have a clear understanding of the governing rules.” Providers also need time to appropriately prepare for the changes, so they may be fully engaged in the new program. Speculators predict a January 2018 start date to align with the calendar year and annual financial reporting.


The importance of getting ahead

Although these programs have yet to take their full effect, US health care has made strides towards consistency and standardization over the past decade in an effort to bring down skyrocketing costs. As it stands, the price tag for the care of an increasingly aging American population is unmanageable. Scaling is a necessity. Programs such as BPCI have shown that bundled payments are a solution that works for all stakeholders. As CMS leads the trend through CJR, other payers are following suit. The organizations that are going to come out of this transition ahead, are preparing now.


It’s becoming clear that delaying the expansion of CJR and other bundled payment methods does not mean wiping them out altogether. From countless ‘trials’ we can see value-based care as, not only a preferred method but a necessity. For providers, figuring out ways to scale accordingly -- reconstructing care networks, integrating new tech, etc. -- runs parallel with success in the inevitable progression towards bundled payment.