LOUISVILLE No surgeon is perfect. Even the most precise, experienced surgeons have a margin of human error. But, what if a robot could change that? What if surgeons could achieve perfect surgical precision? And, then, what if a healthcare system redesigned its service lines and access points to better reflect how patients experience episodes of care and how they want their needs to be met?
All these hypotheticals are converging in reality in orthopedic care at KentuckyOne Health in Louisville. Through a combination of new robotic technology, redesigned care plans, and new access points, KentuckyOne Health Orthopedic Associates is designing the ultimate patient experience.
With 12 employed orthopedic surgeons and two fellowship trained double board certified primary care sports medicine specialists, KentuckyOne Health Orthopedic Care covers the full spectrum of care from joint replacements to sports medicine and from spine surgery to trauma.
Greg Rennirt, MD, orthopedic surgeon and physician market leader of the West Market (Louisville area) for KentuckyOne Health, says, “What we’re trying to do from a service line perspective is redesign our care to better mirror the way the patient sees our healthcare system. We’re trying to set up teams around episodes of care so there is more of a seamless transition.” These pathways are horizontal across multiple specialties, rather than the vertical silos of the past in medicine.
KentuckyOne recently completely redesigned its total joint replacement care plans to follow this new philosophy, including opting into the Centers for Medicare and Medicaid bundled payment program. (For more information, see the sidebar Bundling Payments, Improving Outcomes on page 12.) “Probably the biggest difference in what KentuckyOne can offer versus all the other orthopedic surgeons in Kentucky is our total joint program. What we have in our total joint program through our bundled payment program with CMS is really unique,” says Rennirt. “We’ve significantly improved outcomes. We’ve dramatically cut length of stay. We’ve cut the cost of surgery. Patient satisfaction is through the roof. That really is a differentiator.”
Redesigned transitions of care and changing reimbursement models are only part of the equation for KentuckyOne’s total joint program. The addition of robotic hip and partial knee replacement is revolutionizing outcomes and has the potential to exponentially increase the lifespan of implants.
While robotic joint surgery has been around for several years, it has been slow to come to Kentucky. However, in December 2015, Jewish Hospital was the first in the area to launch a robotic joint replacement program with the MakoPlasty™ Interactive Orthopedic System, a product of Stryker®. For Stryker, the Shea Orthopedic Group, part of KentuckyOne Health, was the fastest launch in company history in terms of the number of patients who had robotic surgery within the first 90 days.
Now six months into the robotic program, orthopedic surgeon Arthur L. Malkani, MD, who began Jewish Hospital’s total joint program in 1997 and is with Shea Orthopedic Group, says he and a fellow surgeon have done a total of approximately 65 robotic surgeries, about 50 of which have been hip replacements and 15 of which have been partial knee replacements. Robotic total knee replacements were recently approved by the FDA, according to Malkani, and he hopes to have that technology at Jewish Hospital by the end of the year.
Using a pre-operative CT scan to map the patient’s anatomy, the Mako robotic system provides surgeons real-time information on correct implant size, position, and leg length to allow perfect placement every time. Malkani likens the robot to using GPS navigation in your car. “GPS is telling me where to go, but I’m driving the car,” he says. With the robot, “If I deviate, it just shuts off. It’s so precise. I can’t imagine doing this surgery without the robot now.”
One hundred percent of Malkani’s hip and partial knees replacements are now being done with the robot. For hip replacements, his preference is the direct superior approach, but he says the important thing to note is, “The robotic system can do hips from any position you want based on the patient’s needs and best interests.” With traditional partial knee replacement, the procedure is only perfect an average of 70 percent of the time. With the robot, precision jumps to 95 percent. “It takes the stress out of surgery when you have a system that’s extremely accurate in telling you what size you need and where to go,” says Malkani.
Very active 74-year-old Paula Hammer had a total knee replacement done by Malkani in 2010 before the Mako robot was available. She returned to Malkani because of pain in her other knee, and he opted to do a robotic partial knee replacement in January 2016. While Hammer admits she babied her first knee after surgery, she was walking the Masters Tournament three months post-op.
This time, however, her results were even better. “The other knee I woke up and I was groggy and uncomfortable. This one I woke up and I was ready to party. It was a totally different experience,” Hammer says. She was home two days after the robotic partial knee and walked up the stairs to bed. “Yes, there was pain, but it was nothing like before,” says Hammer. Now she is back to exercising and playing with her grandkids just like she did before.
Logan Mast, MD, is the newest member of Shea Orthopedic Group, having joined in September of 2015. A Louisville native, Mast attended medical school and residency at the University of Louisville and did a sports orthopedics fellowship with Andrews Sports Medicine group in Birmingham, Al.
A self-proclaimed generalist, Mast has a patient population that is half orthopedic patients and half sports medicine patients, a good representation of the breadth of surgical options available at Jewish Hospital. He also assists Raymond Shea, MD, with the care of the U of L football team.
Mast is certified to do Mako robotic surgery but has not yet performed surgery with the robot. “The implants are similar or the same as the implants we’ve used in the past. It’s the reproducibility of the robot that allows us to be more consistent with placing the implants in the correct position for a given patient, that allows us to hopefully maximize the life of the implant itself, and therefore the length of benefit that the patient will see from that partial knee replacement,” Mast says.
Sports Medicine = Arthroscopy, Not Just Athletes
Often misunderstood, sports medicine is a surgical subspecialty of orthopedics. However, there is also a new breed of primary care sports medicine physicians, a subspecialty of family practice, who focus on non-surgical treatments. KentuckyOne Health employs both to meet the comprehensive needs of its patient base from weekend warriors to collegiate athletes to aging patients with arthritis.
When it comes to sports medicine surgery, Mast says, “As sports orthopedists, we don’t only treat athletes, but also weekend warriors and the general public, alike. Some of our procedures are done through a scope in a minimally invasive manner, called arthroscopy. The ability to treat many problems through a scope is one of the defining features of a sports orthopedist.”
A large portion of Mast’s practice is hip arthroscopy. “Recently we’ve been able to treat problems like labral tears in the hip that were untreatable before or at the most extreme were treatable with open surgery only. Now we can do them as an outpatient procedure through small incisions that require less risk of bleeding and infection,” he says.
Rennirt, who joined KentuckyOne in 2010 because he was looking to be a part of a large multispecialty group, says his sports medicine and shoulder practice has evolved as he has gotten older. He no longer participates as an on-the-field physician but sees more rotator cuff injuries, osteoarthritis patients, and worker’s compensation shoulder injuries.
Arthroscopy continues to be the center of his practice, but he says new advancements in devices are improving the patient experience. “In shoulder replacements, newer implants help to compensate for rotator cuff deficiencies, which used to be a contraindication to doing a shoulder replacement, and synthetic grafts for the shoulder, called Superior Capsular Reconstruction, treat people with irreparable rotator cuff tears,” Rennirt says.
The Healing Power of Biologics
When it does come to treating athletes, according to Rennirt the newest horizon is biologics. “The big field in sports medicine right now is osteobiologics, trying to harness the body’s healing capacity and concentrate it to heal an athlete,” he says.
Paul McKee, MD, is a primary care sports medicine physician who joined Shea Orthopedic Group in 2010 and specializes in diagnosing, treating, and managing non-operative musculoskeletal injuries. McKee serves as the team doctor for the U of L baseball team and sees athletes from all sports on the U of L campus. He has a particular interest in biologics, such as platelet rich plasma (PRP) and bone marrow injections, which he has been using on athletes for years. “The focus is to try and promote healing and prevent surgery whenever possible. Ultimately, we try to get athletes back to sport safely and quickly,” he says.
A New Model for Emergent Musculoskeletal Care
McKee posits that access to care is one of the most frustrating and challenging things for patients in healthcare today, particular orthopedic patients. For a patient who suffers a musculoskeletal injury after hours, the choices are limited – either urgent care centers that may not be trained in such injuries and ultimately refer you back to your doctor in the morning or emergency departments that can have long wait times as more acute medical emergencies take precedence.
That’s why McKee has been advocating for an after-hours walk-in clinic for years, and he’s finally getting his wish.
KentuckyOne Health is opening its first orthopedics and sports medicine walk-in clinic at Medical Center Jewish Northeast in Louisville, set to open in August 2016. “The goal of the walk-in clinic is to provide a high level of musculoskeletal care in an after-hours environment, therefore increasing access to musculoskeletal care that is specialized, while at the same time providing it in a much more efficient manner,” says McKee.
In addition to improved access and specialized care, the walk-in clinic is designed to be more cost effective than existing treatment options. “Instead of an emergency room charge that could be thousands of dollars, it would be a simple office visit charge, and you have follow up in the appropriate setting already pre-established,” offers McKee.
The target audience for the clinic is any patient with a musculoskeletal injury who is at least seven years old. Staffed by a new primary care sports medicine physician, Neil Patil, MD, and sports medicine trained physicians who will rotate there a couple of days a week, the clinic will offer first floor walk-in access and a full range of imaging services, including X-ray, CT, and MRI. For any patient who needs a higher level of care, such as surgery, the clinic has access to all KentuckyOne Health facilities.
“We have an obligation as healthcare providers and as large hospital networks to provide care at a high level in an efficient way that is also fiscally responsible. This after-hours office is going to do all those things,” says McKee.
BUNDLING PAYMENTS, IMPROVING OUTCOMES
On July 1, 2015, KentuckyOne Health opted in to the Centers for Medicare and Medicaid (CMS) Bundled Payments for Care Improvement (BPCI) initiative in orthopedics for lower extremity joint replacements. Explains Greg Rennirt, MD, orthopedic surgeon and physician market leader of the west Market (Louisville area) for KentuckyOne Health, “It’s a way of bundling orthopedic services to control costs for CMS, but what it does is it actually allows us to spend money to try to improve outcomes to drive down costs. Instead of just chasing cost reductions, it actually allows us to spend money to try to make our patients safer, and to cut down on complications, which in the end will result in cost savings.”
KentuckyOne Health initiated the program at six of its facilities and has the only CMS orthopedic bundled payment program in Kentucky. As part of the program, KentuckyOne launched a Joint Academy. Pre-op counseling was offered to orthopedic patients prior to the bundled payment program, but the Joint Academy is now a mandatory educational class for any patient having an orthopedic procedure. The class is led by a KentuckyOne Health nurse navigator and discusses all aspects of pre-op and post-op care, including discharge planning.
While all orthopedic surgery patients attend Joint Academy, only Medicare patients are part of the orthopedic bundle at this point. As part of the bundle program, those patients also meet with a KentuckyOne Health Partners orthopedic health coach at the Joint Academy class. KentuckyOne Health Partners, a division of KentuckyOne Health, is a care management company with a clinically integrated network of providers, facilities, and ancillary services that collaborate to ensure high quality, cost-effective care.
“We feel the value of Joint Academy is that patients go into surgery knowing exactly what to expect, knowing exactly where they are going to go at discharge, and they have met their orthopedic coach that is a KentuckyOne Health Partners Health Coach who follows them for 120 days post-operatively,” says Ann Spencer, KentuckyOne Health Partners regional director for Care Management. “We’ve seen great success at lowering readmissions due to that relationship that starts immediately in that classroom setting.” Case in point, KentuckyOne readmissions for elective hip and knee replacement were 17 percent before the program. Now they’ve been reduced to 10 percent across the health system.
Another advantage of the bundle program is that KentuckyOne has obtained a waiver from CMS so patients can be sent home on day one or two post-op rather than staying for the otherwise obligatory three nights, allowing patients to start the healing and therapy process earlier.
Spencer also says physicians have been instrumental in developing consistent evidence-based protocols and standardizing care across the continuum to improve quality and reduce inconsistencies across the market. “It’s been a real win for patients and for the system,” she says.