The way we deliver care across the episode is changing, driven by the pursuit of a patient-centric model – an undertaking that can only be achieved by breaking down the silos of a fragmented health system.
The upcoming ACPM Interdisciplinary Conference on Orthopaedic Value-based Care provides a game-changing opportunity for surgeons, anaesthesiologists, nurses, and healthcare administrators to join forces in uncovering cutting edge industry trends and insights. In the first of our special series, we spoke with conference speaker, Dr. Ronald A. Navarro, MD, Regional Chief of Orthopedic Surgery, Kaiser Permanente Medical Group, about his best practices for value-based care.
Follow along with us as the industry experts share their strategies for improving patient outcomes while streamlining care delivery and reducing expense for all involved.
Let’s start by talking about your background as an orthopaedic surgeon. How has the shift to value-based care influenced the work that you do?
I certainly wasn’t thinking about value-based care when I graduated from the University of California-Santa Barbara in 1988, or during my orthopaedic residency at Harvard General UCLA Medical Centre in ‘95. My Shoulder, Sports Medicine and Arthroscopy fellowship was at the University of Pittsburgh in ’96, and that training was pretty much the old way – fee-for-service plus the academics and this idea of indigent care being in a county system. It was irksome to see these people who had issues and problems that were not managed in advance.
From ‘96 to ‘97 I did one year of private practice in Los Angeles, and again it was really fee-for-service driven. Then in ‘97 I joined Kaiser Permanente – it’s essentially a prepaid program. There were a lot of aspects of it that resonated – this concept of preventative care, keeping people healthy upfront so you don’t have to provide more costly care later.
I think we were doing value-based care without that moniker for a long time, where we defined it as “value equals quality over cost,” aiming to drive out the cost and drive up the quality. But due to fact that every single procedure creates a payment, we humans cannot avoid conscious or unconscious bias in the power of the dollar bill.
Now I tell patients all the time: I seek the truth. If the truth means an operation after you and I discuss it so you have knowledge and understanding, and there’s shared decision-making, then that’s what the truth will be. But you don’t always need to be motivated by an incision on your skin to just do some better quadriceps rehab for the lower extremity or delta rehab for the upper. That’s where I can see it’s been a benefit to grow up in a setting where you try and seek the truth medically, and dollar bills are not really a motivating factor.
Why is it important for surgeons to have the opportunity to connect and collaborate with other physicians, nurses, and healthcare administrators when it comes to improving the model of care? How is this collaboration important for clinical transformation?
In order to make that a reliable earlier discharge without negative consequences for the patient – you can probably say, “Hey, you’re going home today,” on day 0 and just think, what else do I need to do? I don’t need anyone else – I’m the surgeon, I can discharge them earlier. And you’re saving the organization money; you’re getting the patient out earlier.
But in order to make sure the patient has a good experience and they’re not feeling “pushed out,” it’s better to collaborate with multitudes of other people. This includes physical therapists who rehab the patient and make sure they’re home safe, nurses who visit the home or take a phone interview with the patient to discuss things like stairs and throw rugs, and discharge planners who avail themselves of knowledge of the patient’s issues so they will be able to have help at home.
The surgeon could do all that, but the surgeon doesn’t have time and those other people are vital in thinking of things the surgeon doesn’t, such as anesthesia – providing blocks, which are short acting, but yet allow for rehab in the recovery room.
If you work with all the key parts of the team that touch the person, you’re probably more likely to have a successful implementation of a new paradigm. So the surgeon, to think they can go at it alone, probably would have less success at sending patients home the same day.
Can you share a brief description of your speaking topics for the conference? Why are these topics important to you, personally?
“Surgical Care Pathways for Hip Fracture”
Let’s say a patient shows up at your doorstep with a hip fracture, and they haven’t been to see the doctor for several years. How can we enhance their recovery? It’s a multi-modal pathway that includes pain management – some of the medical centers are giving blocks to a patient’s hip in the emergency room. So they do a regional block rather than giving them shots of morphine or pills of Norco. Instead of doing that, you give them a block so they have pain relief – and when it comes time for surgery, they’re not lethargic, or they’re not eating less, because some of those agents cause nausea.
And then there are the anesthetic agents during the procedure and afterward to minimize narcotics and maximize recovery and activity. One of the biggest reasons we do try to get them up by two days is that obviously you want to fix the hip, but you also want to get them moving and mobilized. Then you ward off venous thromboembolism, VTE, blood clots, and pulmonary emboli, and you ward off the possibility of getting bed sores in the bed because they’re not immobilized and laying around, and you decrease the risk of pneumonia because they’re not lying recumbent – they’re sitting up, they’re clearing their pulmonary tract more easily by being in an upright position.
Those are generalities of how an early recovery after surgery model can help. And I think that also speaks with regard to the hip fracture pathway.
[Dr. Navarro will also be presenting “The Big VTE Prophylaxis Debate: Orthopedic vs. Hospitalist Perspectives.”]
How is the shift to value-based care impacting the patient across the episode for hip fractures? Why is it so important from a patient experience perspective?
For primarily elderly patients that experience a hip fracture, I want them to show up at the two-month or three-month appointment and actually walk in, either with a walker or walking by themselves. But I want them to be alive. Old data, which is decades old probably now, showed that the mortality rate was around 50% at a year. I don’t think it’s that high now because so many efforts have been put forth to improve care. But still, there are some patients who die, so you want to minimize that, obviously, and you want patients to have a life they deem still has quality.
You do this by getting them up early, by keeping them without a lot of pain, by giving them the surgery within the first two days (and preferably within the first day if they’re medically cleared), and then by getting them mobilized and walking around. And that’s not just a good therapist, it’s a good therapist coupled with a good surgery and surgeon, coupled with a good anesthesiologist who doesn’t keep them snowed, and a good nursing team that mobilizes them to get them going. It takes all that multi-disciplinary effort to help ensure they walk into your office at two-months with a walker (or without one).
Can you share any patient stories that demonstrate this?
I do a lot of joint replacements, and the degree of pain relief in the patients is so tremendous. Patients come in and their faces change; they’re not angry anymore, they’re not argumentative, they’re just happier people because this chronic pain has been largely alleviated. Still probably the biggest enjoyment I get is seeing that I actually helped a person, that they’re whole behavioral approach to life has completely been altered in a positive way.
What does the future of value-based care look like to you? What’s next?
We need to partner and bridge the patient’s experience from surgical care back to adult primary care without there being losses in those transitions, because that’s where patients can have negative results too.
I think integrating systems can help – and I’m not trying to make an argument only for Kaiser Permanente because I think it’s better. I think all the systems—in order to be viable in America given the cost structures, etc.—are going to have to try and integrate the care of the patient. Even in private, if the guy says, “I just did my surgery, I don’t really know what happened to the person and their diabetes,” I don’t have to know about what happened to their diabetes in my system, but I know someone else takes the patient back into non-surgical care and plugs them back into episodic care that cares for them holistically with regard to their non-surgical problem.
I think that’s the future of all this – is making all the pieces talk to each other, keeping the patient in the center, so that the patient continues to thrive.
The American College of Perioperative Medicine hosts the Interdisciplinary Conference on Orthopedic Value-Based Care, February 9-11, 2018, in Newport Beach, CA. An immersion weekend that covers the operational, financial and clinical aspects of orthopedics practice, the conference is an opportunity to learn more about the Perioperative Surgical Home – Enhanced Recovery model.
OrthoServiceLine.com is pleased to sponsor this event. Enter OSLTRANSCEND at registration to claim your 10% subscriber discount.