Same-Day Surgery Vol. 42, No. 7; p. 73-84

Several years ago, several high volume North Carolina surgeons decided there had to be a better way to handle total joint surgeries than the status quo. Total joint surgeons in their region were among the top 10 nationally in volume. Yet, some didn’t believe their goals and objectives were aligned with the hospital systems where these surgeries took place. The solution: an ambulatory total joint surgery program that has succeeded beyond their early expectations. The move to an outpatient setting largely was a clinical decision, says Steve Lucey, MD, co-founder and president of Delta Joint Management, LLC, in Greensboro, NC. Lucey runs his private practice, Sports Medicine & Joint Replacement Center in Greensboro, which is an affiliate of Wake Forest Baptist Health. “We noticed total joints were heading to outpatient because of better pain management, no drains, and other clinical pieces,” Lucey recalls.

It helped that a new, state-of-the-art, 60,000 square-foot ambulatory surgery center (ASC) with 13 operating rooms and two procedure rooms was under construction in the area. “We went to the Surgical Center of Greensboro facility and said, ‘We can bring you total joints,’” he adds. “We’ve been very pleased with bringing total joints into the facility,” says Jennifer Graham, RNFA, CASC, CNOR, the CEO of Surgical Center of Greensboro, LLC. “This is a service we can provide within the community from an outpatient standpoint, and we have received great feedback from patients.” The new ASC facility, which opened Aug. 31, 2017, contains 10 overnight beds to handle patients who need an extended recovery, including total joint patients. In its previous two locations, there were nine overnight beds, and the surgery rooms were small (less than 400 square feet). The new facility is one of the largest in the United States, and its operating rooms, accommodating total joints, are 625 square feet, large enough to comfortably handle the larger equipment and instrumentation, Graham says. “We made sure the flow of patients was streamlined and accommodating,” Graham says. “This has been a great opportunity and learning experience for staff, and it’s a new service line to focus on, a new challenge.” Lucey and three additional surgeons handled about 95% of the community’s total joint volume. They joined forces through Delta Joint Management and each contributed to starting the new organization. “We’ve had the good fortune of designing everything in the ASC for the total joint center, including two larger rooms and committed capital expenditures for total joint equipment,” Lucey explains. “And we partnered with the surgery center to educate the staff, creating pathways, protocols, and inclusion criteria.” Delta Joint Management also developed a bundled payment model that greatly simplifies charges for patients, lowers costs, and spreads risk among providers. The organization negotiated a contract with North Carolina Blue Cross/Blue Shield to handle their privately insured population’s total joint surgical and after-care needs. The program has saved North Carolina Blue Cross/Blue Shield more than $1 million. It’s also reduced out-of-pocket and copay expenses for patients, cutting their costs by at least half, Lucey says.

The overall surgery cost is 20% less than the typical rate, which saves the insurer thousands of dollars on each case. Patients typically pay 10-20% as coinsurance on the bundled cost of the surgery. This means their out-of-pocket costs are considerably lower than if they underwent surgery elsewhere, Lucey explains. It also gives patients peace of mind. Once they’ve paid their copay, there are no surprise expenses. “So, when they show up at the doctor’s office or therapist ... there are no more bills or copays,” Lucey says. “The fact that they don’t get billed — they love it.” Within 15 months of opening the total joint program, it’s expanded to 11 surgeons from all the private practices in Greensboro. More than 150 patients underwent total joint surgery, and none experienced infections or needed hospitalization. The program could serve as a nationwide model as more ASCs and physicians turn to same-day total joint services. “We have had so many people calling and asking about this model,” Lucey says. “So, we’ve shared our story.” The program’s success hinges on patient experience, and anecdotal evidence suggests that has been very positive. “For patients and doctors and even the surgery center, this has been a fantastic experience,” says Frank Rowan, MD, an orthopedic surgeon with Southeastern Orthopaedic Specialists and a partner with Delta Joint Management. Surgeons nationwide have contacted Delta Joint Management to learn more about how the program works, Rowan notes. “By 2025, I think 50% of total joints will be outpatient,” Rowan predicts. “It will expand and be in some ways very rapid.” The bundled payment aspect to the ambulatory total joint program also might spread. In the nation’s evolving healthcare market, shifting some or most risk to providers helps ensure accountability, efficiency, and quality of care. It also keeps costs lower for patients.

Surgeons take on the risk of complications post-surgery, although there are risk ceilings for especially serious events, such as a heart attack, says Donna Garvey, CMPE, practice administrator of Sports Medicine & Joint Replacement and executive director of Delta Joint Management. “If a catastrophic complication occurs where costs exceed the agreedupon limit, then the bundle is busted, and the episode returns to a classic fee-for-service model,” Garvey explains. “This protects the business model, which is advantageous for all parties. Having said that, we haven’t had any busted bundles.” Delta Joint Management handles risk through patient inclusion assessments, patient education, communication between physicians and all post-surgery providers, including case managers, and tracking patient data to watch for complications. “We’re not having many complications,” Garvey says. “The most common thing we’re seeing is a need for some additional physical therapy.” Patients receive a good clinical experience at a lower cost, and physicians enjoy a positive collaboration with the ASC, Graham says. “From the doctor side, I feel like we’re continuing to work together to improve patient outcomes.”