Becker's Spine Review

20 Thought Leadership The biggest challenges & opportunities in orthopedics: Q&A with OrthoIndy's president, interim CEO By Alan Condon E d Hellman, MD, president and interim CEO of Indianapo- lis-based OrthoIndy, has navigated several healthcare challeng- es over the last 30 years as an orthopedic surgeon. Chief among the challenges facing the industry today is the battle to maintain independence amid significant consolidation and as health- care continues its shi from fee for service toward a value-based care model. Dr. Hellman spoke to Becker's about how OrthoIndy aims to capitalize on outpatient migration, value-based care in orthopedics and the big- gest opportunities for growth in the coming years. Note: Responses are lightly edited for style and clarity. Question: What do you see as the most pressing issue facing orthopedic practices at the moment? Dr. Ed Hellman: e biggest thing is how to stay independent. e last decade or two we've seen reductions in reimbursements for professional services while reimbursements have stayed high on the facility side. At the same time, overhead has gone up, such as malpractice insurance, in- formation systems and compliance. ese things are very costly, and that's decreased the margins that an independent orthopedic group operates under. e successful groups have found ways to develop ancillary in- come streams, whether it's ownership of therapy or imaging centers or surgery centers. In our case, we have a physician-owned hospital that's part of that as well, and that has allowed us to stay independent of the major health systems. Q: Do you see a place for small- to medium-sized orthopedic groups in the future? EH: I would not be confident if I were in a group of three or four phy- sicians. I think they're going to find it really difficult to maintain their income level and to be competitive. I think there is a role for indepen- dent groups, but I think that size is going to be important. Q: What are three healthcare trends you're keeping a close eye on? EH: In the orthopedic world, there's the move to outpatient. Over the next several years, I think you're going to see the hospital be a place where orthopedic trauma and surgery on patients with major medical comorbidities are done. Patients who may need intensive care levels will still require hospitalization, but most orthopedic cases are going to move out of the hospital into an ambulatory world. We're also looking at videoconferencing and telehealth systems. I'm not so sure how big a part of orthopedic care it's going to be, but I do think it will play a role. It's very difficult to do a physical exam over a video link, so it won't really replace a patient coming in to have their knee, shoulder or spine examined. But there are situations where it can be extremely helpful and user-friendly for both the patient and the physician. For example, a patient who's concerned aer surgery about swelling, what their incision looks like, or whether or not they're mak- ing the right progress with physical therapy, those types of situations can be easily handled over video. You can see an incision and see if a leg is swollen — many times that can help avoid patients coming into the office. Another issue is how healthcare will be paid for. Obviously, the whole fee-for-service, third-party payer system is coming under a lot of stress as we approach 20 percent of GDP going to healthcare. A lot of our companies are looking at their healthcare spend as something that's really hurting their bottom line, and it gives us an opportunity to develop more innovative models, such as direct-to-employer con- tracts and bundled payment programs. e buzz term is "value-based care," but it's very difficult to find value, so I think these other ways of looking at care are going to be very important. at's also one of the reasons why smaller orthopedic groups might struggle — it really re- quires some degree of size to be able to participate in these programs. Q: How has OrthoIndy approached bundled payment pro- grams for joint replacements? EH: We've been very successful with joint replacement bundled pay- ments, but there's only so much you can get out of them in terms of savings. When bundled payments started, we looked at our program to determine where we could cut the fat. We put together a lot of programs regarding patient education and expectations in terms of the whole epi- sode of care, especially what happens aer you leave the hospital. If you educate patients about what they need as opposed to what they say they want, a lot of the time you can eliminate a lot of unnecessary care steps. We really cut back the number of patients leaving the surgical facility and going to another inpatient facility for rehab. We diminished dis- charges to extended care and acute rehab facilities. Some of the patients who may have previously gone to a facility now go home with some degree of home care. We also assessed home care usage. A lot of people used home physical therapy or home nursing almost routinely, so we questioned if that was necessary or can we get some of the people who are going home with home care into an outpatient physical therapy location. en we looked at the patients who were going to outpatient physical therapy facilities and asked, "Can some of these patients do their rehab on their own?" Especially now with the use of video assistance, wearables and other technologies. All of this has really diminished our post-dis- charge spend. e problem is once you've instituted those programs, what's next? A lot of the bundled payment programs, like the [Bun- dled Payments for Care Improvement] program, each year you're ex- pected to cut more, and it becomes very difficult once you've made these initial program changes. So, we're not currently participating in that program because we don't see where it goes from here. We think that initially a lot of good came out of bundled payments, but there's only so far that you can take them. Q: Where are OrthoIndy's biggest opportunities for growth in 2022? EH: Because we have a physician-owned surgical hospital, we're sort of a hybrid: We're seeing some of the advantages and some of the stresses that practices see, and some of the advantages and stresses that hospi- tals see. Clearly we need to develop and expand our outpatient strategy because just like the community hospital down the road, procedures

• Cover