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Ortho Surgeon Q&A: Regulatory Mandates, Quality Improvement, and AI in Healthcare

In October 2023, Force Therapeutics CEO Bronwyn Spira hosted an unfiltered and wide-ranging panel discussion with three of the most respected and accomplished orthopedic surgeons and executives in the country:

Missed the panel? Access the full recording here.

Below is a collection of the most impactful highlights from the discussion, edited for brevity and clarity. The full panel discussion recording can be accessed here.

Key context: A consistent trend in the healthcare landscape in recent years has been the growing emphasis on care accountability for containing costs and improving quality outcomes.
The Centers for Medicare and Medicaid Services (CMS) has been incentivizing the transition of the U.S. healthcare system from fee-for-service care models to value-based care models, and by 2030 aims to have “all Medicare beneficiaries…and the vast majority of Medicaid beneficiaries in a care relationship with accountability for quality and total cost of care.”
For example, the 2023 updates to the CMS hospital Inpatient Quality Reporting (IQR) program make the collection and reporting of THA/TKA patient-reported outcomes (PROs) mandatory starting April 2024.

Q1: How have these regulatory mandates and updates affected how you deliver care? And how significantly have things changed for you since you started in this field?

Dr. Iorio: With the advent of bundled payment care episodes in 2013, I think we all learnt a lot of valuable lessons about the way care was delivered, and we looked for ways to deliver that care more efficiently. And I think we changed the way total joint replacement was delivered; we became much more attuned to the value of care management and the need to communicate with our patients. And now we look for tools to make that easier: we look for protocols; we look for patient education materials.Even though the bundled payment system hasn’t exactly taken off or been extremely popular, the discipline imparted on orthopedic surgeons who do joint replacement through those methodologies has really revolutionized the way we do joint replacement, and it's made the move toward outpatient surgery more predictable.

Dr. Grady-Benson: Early in my career, when patients were admitted the night before surgery, we didn’t know much about them at all: we had no definitive quality metrics; they stayed in the hospital for 4 to 5 days, and that was considered a win.

So the transformation from that perspective to now, where we’re really much more laser focused on more objective outcomes measures, when we’re much more able to talk about adverse events and learn from them and improve care pathways. That whole transformation, I think, is without question better for patients and better for surgeons actually.

Dr. Meneghini:  The fundamental question in the current realm is regulatory value versus quality. Under the mandatory CJR program, if we were going at risk for a bundle, we had to look at cost accounting, and what was the true cost of care. And if you look at the value equation, it’s how much resource consumption are you using to treat that patient, and what is the quality outcome. And the mandatory bundle then forced the system to look at it and ask what cost was being applied to get that high quality outcome, and embedded in that was the ability to do gain-sharing of savings between the surgeon, staff, and hospital.

We did the mandatory CJR bundle with gain sharing for a year. It drove costs down, quality up, and then unfortunately as soon as the mandatory bundle ended, the system went right back to fee-for-service, and we watched the alignment and the incentives of the physicians in the hospital system just disappear overnight; the physicians stopped worrying about it, and costs went right back up.

So I think what I learnt from the mandatory CJR experience is that some of these mandates and alternative payment models, if done properly, can drive alignment to drive value from quality and cost reduction. But if it’s not structured properly and just being mandated like a government coming in and hitting you over the head and mandating it–if it's not done properly–it’s not going to truly drive value. That’s the difference here; that alignment piece is really critical.Dr. Grady-Benson: I couldn’t agree more with that. When hospital systems and surgeons are aligned for the betterment of the patient and are willing to have a discussion about the give and take that that requires and the quality metrics that they depend upon and decide upon and agree upon, then things go much better.

In today’s healthcare environment, everyone has a different idea and definition of what cost is; the patient’s, the surgeon’s, the hospital’s, and commercial insurance definitions of cost are vastly different. So that’s not aligned–that’s the world in which we live. But if we can make some decisions about quality improvement initiatives that are agreed upon, it makes the game a lot easier.

Q2: What were the actual challenges involved in these value-based and bundled payment models? And how are you thinking about those challenges now?

Dr. Meneghini:  The challenge related to value-based care arrangements was some of the burden; during the mandatory period, some people adopted nurse navigators to coordinate care and attorneys to ensure compliance, so that cost of personnel is high and burdensome.

And this is where we rely on technology now to help us, because technology probably has a better value proposition sometimes on certain things than the heavy resources. Ultimately you’re going to have to pick either people or technology or a combination to implement and oversee value-based arrangements. But either way, it requires more resources ultimately.

Dr. Iorio: You have to remember that CMS sees the error of its ways, in that the mandatory nature of the Comprehensive Joint Replacement model (CJR) was realized to have been a failure. Having said that, all bundles in the future will be mandatory. They will not be voluntary. So CMS wants practices to learn how to do these bundles properly.

Ultimately, getting the resources so everyone under value-based arrangements can play in a level playing field will be difficult, but I think we know what those pieces are now: you have to have a good EMR, you have to have some sort of patient engagement technology, you have to have alignment between hospitals, surgeons, vendors, providers so that everybody shares in the risk and the benefit from care delivery. And how we tie the primary care doctors and the other longitudinal orthopedic care into the health of the patient and take the high-risk patients into account as well is where the rubber meets the road.

There are also some discussions about having historical models for high-risk patient care delivery in certain places to be given accommodations for their comorbidity burdens and things like that, so that the higher-risk inner city hospitals aren't competing with the private practices out in the suburbs on a one to one basis like they did in the Bundled Payments for Care Improvement (BPCI) initiative and CJR model. So CMS understands now that maybe Medicare for somebody in an underrepresented area isn't quite the same as somebody in a suburb and that there has to be some accommodations made for that.

But technology and alignment and cooperation among the patient, vendor, hospital, and provider are going to be absolutely necessary to make this successful.

Q3: How do you think about data in the context of shifting toward more value-based care models? And how does it affect your thinking about risk classification?

Dr. Grady-Benson: I applaud Rich’s eloquence in that previous discussion there. I would add that, at the basis of everything that Rich and Mike have said so far is data and data management. If you don’t measure it, someone else is going to measure it for you. And so the number one thing that I ask for in terms of resources is making sure I’ve got a data platform at the hospital and in my private practice group that is accurate, adjudicated, timely, efficient, and can be trusted. And when the data is trusted by all the surgeons in the hospital, then the outcomes speak for themselves.

The people you need to do this are absolutely necessary to make this happen in an era where we’re also charged with high Press Ganey scores and patient satisfaction, in a time where, post-COVID, people are a bit more tense or irritable and they have very high expectations. But the data foundation–I can’t emphasize enough–is of paramount importance to make value-based or alternative payment models successful, no matter what legislative or regulatory mandate happens.

If you have data to back up what you’ve done and you understand it, and you’re willing to be honest about it and transform your care based upon it, then that makes you ready for any of the challenges that come in the future.

Dr. Meneghini: I think two big challenges here are going to be separating the high-risk patients, big revisions, infections, and patients who are turned away from other centers, and collecting accurate data. So when you say we are treating a high-risk individual–and that value equation is different for high-risk patients because the resource consumption is greater–I believe you should be compensated for assuming that risk if you're gonna be playing in a risk-based value payment model.

Those are, I think, two big challenges ahead of us that we have to get right.

Dr. Grady-Benson: And if you look at the Porter and Lee healthcare value equation from 2013–classic article–healthcare value=patient outcomes/cost. What is not incorporated into that rather simplistic equation–and it's 10 years later now–is the utilization, the resources, and how do we reach out to disparate populations where there are health equity issues that impair their ability to get access to care? That’s another part of the equation that is highly complicated, especially in high-risk patients or highly challenged populations.

Dr. Iorio: We need to make a system that rewards excellence of care for highly comorbid patients when they’ve been optimized. That’s a tough needle to thread, but there are centers that do it. They’re not going to pay us to operate on people by the pound, they’re not going to pay us to operate on people by the comorbidity, but they might pay us if we take care of someone who’s got a high co-morbid burden and we take care of them better than the average has been shown in the past, and then the tertiary centers won’t be so squeezed in a system like this.

It’s just not fair to make someone who serves largely low-risk patients every day to compete with someone who is serving populations with high comorbidities and risk factors.

Despite the fact that some of my compatriots are writing papers that say it doesn’t matter what the patient’s weight is or it doesn't matter what their A1C is, it does matter, and the comorbidities are multiplicative not additive, so we need a system where you get paid for the risk you take, but without taking unnecessary risk or putting the patient at risk. If the system isn’t changed in some way, I don’t really know how we’re going to fulfill the demand here because it isn’t going down–it’s going up quite strongly.

Q4: We briefly mentioned longitudinal care bundles or condition-based bundles; how is that impacting the thinking on value-based care? and how do you think orthopedic surgeons can ensure they have a continued seat at the table and are driving care decisions?

Dr. Iorio: At a 10,000 ft view, eventually orthopedic surgeons will be set into some sort of a longitudinal care bundle with some other managing entity, like an ACO or a hospital or big physician group, and we will be measured on real data: PROMs, real cost data from EHRs…etc.

And that longitudinal care bundle will go out in pieces; it’ll start at a year and eventually it will be a lifetime. And make no mistake about it: the goal is to decrease the intervention rate, and it’s to increase the amount of conservative care and non-operative care because insurers want to save money. And we really can’t afford the amount of care we deliver, despite the fact that what we deliver is high quality.

This is opinion not fact, but right now, if you look at the way E/M coding is delivered. If a provider at their office does 3 new patients with arthritis and gives them 3 knee injections, they make more money than if they did a total knee replacement if they’re CMS patients.

So, that economic model is a bit broken and they’re trying to incentivize us to help patients avoid surgery, but the fact is: our surgery works really well, and finding out where the go/no-go zone is without involving third-party insurance-hired people that decide on arbitrary means–because some of these decision thresholds are different from patient to patient–is a judgment call that someone in an office 30 states away from me can’t really make. So orthopedic surgeons need to be in the middle of that, because nobody manages this like we do, and we have demonstration and proof of concept. We've done it before and we’ve done it well.

Dr. Meneghini: I’m actually excited about longitudinal and condition-based care bundles if we can hang on long enough to the other end of it, because I believe the data will prove what we all anecdotally know…once we have the data to compare non-operative and surgical care pathways and show that intervening early in an appropriate patient saves money, then the equation will change.

The issue is making sure orthopedic surgeons have a seat at the table so that the ethics and transparency of the data are upheld. How we get there is tough, but I’m hopeful we’ll emerge in the right place at the end of it.

Dr. Grady-Benson: I have 2 things to add here, and Mike and Rich are experts on this. Orthopedists are not well represented on the Relative Value Scale Update Committee (RUC), and my personal opinion is that orthopedic surgeons should be in charge and leading guidance of care for arthritis, and here’s where evidence-based medicine tells us to do the right thing, and where our quality initiatives really inform us to do things right.

So yes of course it is well intentioned to continue appropriate non-surgical care and to have appropriate use criteria, and I think our orthopedic academy does a great job at clinical practice guidelines, but there’s going be to a time when we have to start doing predictive analytics on these patients, and I think machine learning algorithms and AI may give us the opportunity beyond the rather simplistic patient-reported outcome (PRO) to really give prescriptive medical interventions that are personalized based on all the medical factors that a single human brain just can’t fathom right now.

Q5: With more surgeries moving to the outpatient or ASC settings and orthopedic patients spending less time in hospitals with providers around a major surgery, how are you ensuring that patients are still getting the education and the support that they need to be successful at home?

Dr. Meneghini: There are a couple of things that are happening here: first, there is a continued increase in the percentage shift of procedures from inpatient to outpatient settings, and at the same time, there is greater and growing demand for hip and knee replacement generally. So it’s like a wave that’s coming, and we’re not quite ready for it because we don’t have enough ASC/outpatient operating rooms to handle it.

And this is really where we are utilizing technology because to manage more patients properly, you need a continuation of education along the entire continuum of care that takes time and effort, and we’ve been shifting from having a person doing that to using technology.

So we used to do in-person education classes, but we started shifting to recording videos and virtual education so that people can do it at their own convenience and pace. And with each generation, people are becoming more facile with technology and more people will embrace it going forward, and so it's all around the continuation of education and care when the patient comes out of the ASC to the home environment. But this will be a challenge for the next 15 years as more and more high-risk patients shift to the outpatient setting.

We’re definitely gradually challenging the fundamental premise that you’re safer in a hospital. That said, post-pandemic data is going to be really interesting to see; what is the rate of medical errors? What is the nurse to patient ratio? I think we might be in a new era now.

Dr. Grady-Benson: Quality improvement in the outpatient setting is very similar to the inpatient setting in the sense that it is the science of process management. You have to manage the process to optimize the patient’s health just like you do in the inpatient setting, but then you have to add the social factors of who is going to take care of the patient? Who will be their care partner? Who will be their recovery coach? All those things frankly take more work.

Dr. Iorio: The pandemic has accelerated the shift to outpatient procedures without a doubt. Patients now find it’s okay to go home and maybe even preferable because you can have disease transmission in the hospital, and the resources available in the big hospitals aren’t quite what they used to be and the staff may be a little less experienced and so the efficiency is a bit worse than before. ASCs have been able to maintain their employees, maybe compensate them a little better and manage to continue their efficiency improvement over time.

Unfortunately, I don’t have a lot of ASCs available for my team here, so we’ve turned our community hospital into more of an efficient discharge place where 70%-80% go home same day or next day, probably under 50% are same-day, but we try, and it has gone extremely well. But it's more education intensive, and without technology that would be much more difficult because of the difficulty of seamless communication, which gives the patients the feeling of security and safety and they have all their education materials on their phone or computer.

Q6: We touched on the theme of data briefly in the context of value-based care, but I want to shift the discussion a bit on the future of data in orthopedic care; how are you thinking about that for the future? And what do advancements in AI and predictive analytics mean for orthopedic care teams?

Dr. Grady-Benson: Historically, we’ve looked at risk factors retrospectively and we use logistic regression, a linear model, of what the risk would be in each scenario. What I’m hoping for in the future is that multiple data sources, fed into AI, can really tell us in each scenario what happens to the patient based on specific optimizations in their health status: when do you operate on that patient? What’s the outcome likely to be?

So I believe that AI and machine learning are going to put the way we think about data on its ear, and optimal classification models are going to be highly predictive and prescriptive in a way that I think will be dramatically better for all of us, but that day is not yet today.

Dr. Meneghini: I think the potential for the future is huge. My concern with AI is the input to the data; if you look at our data sets now, it's not very granular. You have coders in hospitals checking usually simplistic boxes rather than really diving into accurately classifying disease stage or progression. So in order for AI and predictive analytics to work, the data going in has to be accurate and reliable. Once we get there, we can do something with that data.

Dr. Iorio: We now can generate a ton of data with wearables and connected equipment, and we can get paid for looking at that data, and we can debate whether it’s worthwhile or not. But there are 2 issues with the data: 1) someone has to look at it for it to be meaningful, and 2) if you miss something in the data that’s clinically meaningful from a negative perspective, there’s a liability issue too. So with data comes responsibility: it has to be analyzed and we need to know how to interpret it.

And I’ll also add that there’s no substitute for actually looking at and examining a patient and interacting with them in-person, and so we’ll see where these technologies take us but I think we should be smart on where it's really needed.

Q7: We’re all aware how the COVID-19 pandemic kind of exploded the utilization of digital care. Now that we’ve come out of the public health emergency, how would you say the utilization of digital care has changed? And how do you feel your interactions and patient experience with digital care has changed since the pandemic to today?

Dr. Meneghini: The brick-and-mortar traditional healthcare environment that we grew up in is no longer. The pandemic shed light on the fact that it was a house of cards, and all it did was take a worldwide stress to prove it. So the path to get there is through technology, but the technology has to evolve. I think what COVID did was it pushed the accelerator button too fast, and so now the technology is in a bit of a jumbled state and doesn’t seamlessly integrate. It’s going to be a little rocky for a little while but it’s here to stay.

When I started in practice, if someone called with a wound issue, you couldn’t discover over the phone whether it's a little superficial thing or how much it's draining. I need to look at it. But now, every day I get my first case done, I know that I’m going to turn to my nurse and she’ll say I have some pictures for you to look at. And it’s basically a clinic and it’s saving healthcare dollars. The connectivity between your staff and the patient at home is a win.

So I’ll repeat: Our children will not be in hospitals very much, even when they’re really sick. We are learning how to manage health conditions, chronic and acute, at home rather than in the four walls of a hospital system, and technology–paired with a bit of human resourcing–is the only way to do that.

I also believe that the proportion of people who can’t access digital care will decrease year by year. I think we see that every year we see more and more people that our staff don’t have to talk through how to take a photo and add it to their phone or how to get the app on their phone. It’s not fast but it’s happenin

Dr. Grady-Benson: We were fortunate enough to have Force Therapeutics come into our world in April 2020, 2 weeks after the pandemic, and that was just lucky timing. All of a sudden, we were getting a lot more digital connections which were meaningful, in addition to telehealth. The pendulum now has swung back a bit…but we now understand that care has got to go beyond geographical space, there’s just no question about that.

Dr. Iorio: This is a bit tangential here, but for the life of me I don’t understand why CMS has seen fit to say that telehealth can’t go across state lines unless you’re licensed in the state. In what universe does that make any sense? I mean we live in 6 states, so our patients have to lie and tell us they’re in a different state to call us and do a Zoom call or else we won’t get paid for it? The people farther away need more telehealth, not less of it. That’s not fully related to the question here but it just drives me crazy.

But one really important thing here is that institutions or practices that haven’t done a lot of technology have to understand: people take on an electronic health or medical record (EHR/EMR) and they think it’s going to do everything for them. It generally doesn’t. EHRs/EMRs are nice notebooks, but they’re not very facile technology tools, but they can interact with other platforms. So, I would recommend if you get involved in an EHR/EMR and patient platform that you make sure it’s compatible with your EHR/EMR and you can exchange data back and forth, because otherwise it becomes a nightmare.

So your technology departments need to be fully on board…because without compatibility between technologies every interaction sends a note to the inbox and it piles up ad infinitum. And as we talked about before, if you have lots of data and nobody checks it, that’s worse.

Access the full panel recording here.

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