First Outpatient Total Joint Performed in NC

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After participating in the Bundled Payments for Care Improvement program at his local hospital, a group of total joint surgeons in Greensboro, NC realized they could implement similar bundled payments with their Surgical Care Affiliates (SCA) surgery center. They hatched the idea 18 months ago while building a brand new surgical center; now the center is open and they plan to perform the first total joint replacements there at the end of the month.

"Most of my patients were only staying one night at the hospital, so I wanted to work with payers and the surgical center to create an outpatient total joint service," says Dr. Steve Lucey. "It took several meetings with different payers to gain alignment. They were extremely interested in outpatient total joints and we spent about two to three months negotiating the bundles."

As a group of surgeon entrepreneurs, Dr. Lucey and his colleagues — Dr. Frank Aluisio, Dr. Frank Rowan and Dr. Matt Olin — decided to take control of the bundle. These surgeons came together from different practices to create a management company to handle negotiations with the surgery center and payers. Ultimately, they gave a 15 to 20 percent discount on the average amount spent for the total episode of care. The payers agreed to pay the management company a lump sum and the management company would negotiate the best prices for implants, home health, anesthesia and the surgical center.

"We have a situation where surgeons are becoming their own conveners," says Dr. Lucey. "We had a software company build our platform for data collection. We do surgeries and input the data, which is automatically embedded in the American Joint Replacement Registry, and decide who to include or exclude for the outpatient bundles."

The process wasn't without roadblocks, however. Dr. Lucey and his partners are accepting a huge amount of risk for the bundle. The surgeons are at-risk for all care within the 90 days after surgery, so any infections, complications or return visits to the operating room will incur overage costs.

The group negotiated partial knee replacement bundles with Blue Cross Blue Shield that went into effect Jan. 1, 2017 and have completed 33 procedures since then. The program has worked well, and the surgeons anticipate total joints will yield the same success.

"We are passionate about driving the ship. We wanted to take an entrepreneurial approach to put physicians in a better business position and provide patients with better outcomes," says Dr. Lucey. The surgery center includes 23-hour stay capabilities, but Dr. Lucey anticipates many patients will be able to return home the same day of surgery without spending the night. That's part of what will save money in the bundle: where patients are sent after surgery.

"The win is for individual surgeons making decisions for the care of their patients," says Dr. Lucey. "They don't have to send patients to the skilled nursing facility or the hospital-owned home health facility. In our market, if we can save 15 to 20 percent on every case, payers are interested in the bundle."

Dr. Lucey projects to complete 200 bundles within the first year, and hopes to double that number over the next two years.