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Why Physicians Must Be Involved in Joint Replacement Strategies

 |  By jcantlupe@healthleadersmedia.com  
   September 29, 2011

A middle-aged tennis instructor swings her racket fluidly as she belts forehands and backhands. Her movements are robotic as she ambles from side to side, the result, she says, of surgery on each knee.

Another player moves stiffly at the end of a match. Before he leaves, he checks his taped knee. "It aches," he says, "and my doctor is talking about surgery, but I'm not so sure I want to do that."

Call it a Joint Commission -- and I don't mean the hospital rating agency. Players are retooling their aching joints, or thinking about it. Physicians could set up a courtside practice. Talk about net income!

The demand for replacement knees continues to boom, with Baby Boomers pushing the trend, with their aching knees, hips, and other joints. Some 50,000 knee replacement surgeries are performed each year in the U.S and are expected to increase 673% over the next decade, according to the American Academy of Orthopedics.

While middle-aged people are expected to be the largest number of patients, Generation Xers are having knee replacement surgery at an earlier age. Those with obesity, diabetes, or other ailments may also seek knee replacements.

"We are seeing a broadening of the age range of patients who are getting joint replacements," says Peggy Naas, MD, MBA, an orthopedic surgeon and vice president of physician strategies for VHA, and a panelist for the HealthLeaders Medi's Oct. 12 Webinar -- Raise Revenue, Cut Costs In Your Joint Replacement Service Line.  

"We have an increased expectation on the part of the public that things will get fixed. There is the 'boomer' expectation of being forever young."

While hospitals vie for a competitive edge with increasing volumes in knee or other joint replacement surgeries, they are confronting reduced federal reimbursement rates, projected physician shortages in orthopedics, and increased expenses for implants. And the move toward multidisciplinary approaches also will call for more-affordable care and improved patient outcomes, Naas says.

Some hospitals are establishing joint replacement centers and protocols, and building special operating rooms for joint replacements. That has increased efficiency, with physicians performing as many as 8 to 12 surgeries a day, which also improves ROI.

The joint replacement centers are easing transitions for patients from the moment they enter the hospital to rehabilitation and recovery by hiring nurse navigators or joint replacement coordinators.

For a joint replacement team to be successful, it must have executive as well as physician support, says Scott Russinoff, MD, an orthopedic surgeon at Westchester Medical Center and Hudson Valley Hospital in New York and a HealthLeaders panelist on the Webinar. Joint replacement centers, if administered correctly, earn "good money for the hospital," Russinoff says. "Joint replacement centers drive more business and help patients. It's a way of putting all the pieces of the puzzle together."

While the multidisciplinary approach is often discussed, it is not easily accomplished, especially in joint replacement programs, Naas says.

To overcome turf problems, "there should be increased alliances between surgeons and hospitals" in joint replacement programs," Naas adds. "It's very attractive for bundled payments for efficient outcomes. A lot of that fits into healthcare reform." Bundling payments are designed to allow physicians and hospitals to coordinate care and reduce services of little value.

Moreover, physicians should play key roles in the decision-making process for implant purchases, Naas says. Within the hospital, a special "value-analysis team" that includes physicians should be established to have a direct relationship with sales representatives of implant device makers to negotiate cost and standardize programs for improved purchasing, Naas says.

With so many orthopedic devices in the marketplace, the government is trying to evaluate the cost and impact, especially those related to hip and knee replacements, by establishing a $12 million database, or "registry" of the products. The Agency for Healthcare Research and Quality wants to know if these devices work over the long haul, and how expensive are they.

While orthopedic devices are promoted by "surgeon enthusiasts" of particular device/procedures, AHRQ says in a planning document that "the real-world clinical performance of the devices outside of the leading centers that participate in pre-market clinical trials is difficult to evaluate."

"There are thousands of devices and device combinations in use to perform hip and knee replacement and repair procedures," AHRQ states. "The comparative effectiveness of these devices is unknown."

The American Academy of Orthopedic Surgeons has been lobbying for a federally supported national hip and knee replacement registry for years.

Naas says developing a nationwide registry of orthopedic devices will improve clinical outcomes and reduce costs. "In these registries, long-term outcomes are followed for total knee or total joint replacement," Naas says. "We don't have a national registry in the U.S. There are individual health systems that have their own registries, but there is not one specifically for this country. Other countries have them."

In the long run, "we'll find out what innovations" in orthopedic care are paying off, she says.

Joint replacement care will steadily increase with the aging population. And unlike the one tennis player who had two knee surgeries, most people with joint problems don't have surgery, says Todd Davis, vice-president of marketing and developing for Biomet, a Warsaw, IN, manufacturer of orthopedic devices.

"Many people choose not to get (joint surgery) because of the lack of knowledge, fear, or the costs" Davis says. "If these people were included in the projected increases of surgery in the population, the numbers would be off the charts."

 

Joe Cantlupe is a senior editor with HealthLeaders Media Online.
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