A Spectrum of Value and Its Importance in Orthopaedic Trauma

Peter Althausen, M.D., Orthopedic Surgeon; Co-Founder, The Orthopaedic Implant Company

Before the pandemic turned the world more than a little topsy-turvy, the phrase value-based care hovered over nearly every healthcare conversation in some fashion. It was often only an ideal though, nothing more than a target for hospitals and health systems to spend their time aiming at rather than ever actually pulling the trigger on. However, many of those same hospitals and health systems now find themselves in situations where value-based care must become their new reality if they are to continue helping the thousands of patients who need them.

Nowhere is this need for value seen more clearly and felt more sharply than in orthopedic trauma, where convention in delivering care currently continues to reign supreme. Whether it’s in the academic arena, a community setting, or a rural practice, value can play a vital role in improving healthcare across a spectrum of environments, so I wanted to gather the thoughts of a few orthopedic surgeons in a variety of settings to learn about what they’re doing to truly deliver on this idea of value-based care.

I welcomed Dr. Brian Cunningham, an orthopedic trauma surgeon in Bloomington, Minn.; Dr. Ryan Eggers, an orthopedic trauma surgeon in St. George, Utah; and Dr. Owen Kelly, an orthopedic surgery specialist in Russellville, Ark., to provide their expert perspectives and insights.

Dr. Peter Althausen: Why is it important to create value in orthopedic trauma?

Dr. Brian Cunningham: Orthopedic trauma is equal opportunity. Emergent injuries can happen to anyone—a CEO or a janitor, a student or a retired professor. We need to provide the best possible care to all patients. It is critical with limited resources that we focus on creating value-based care. This is not an option but a requirement. We are stewards of the trauma care system and in order to be there for our patients, we need to maximize patient outcomes while reducing the cost. Value mandates both parts—outcome and cost—are measured and managed.

Dr. Ryan Eggers: Value is commonly described as a relationship between cost and outcome. As an orthopedic trauma surgeon, a good patient outcome is my highest priority. However, because I depend on a functional system in a resource-limited environment, my ability to treat one patient is, to a small degree, dependent on how I treat all of the others. So if I can achieve the same—or even better—patient outcomes while decreasing cost, I have added value to the system that will ultimately increase my ability to serve all patients.

Dr. Owen Kelly: I serve a largely rural and blue-collar community. My patients work hard to provide for their families, but as healthcare costs continue to steadily rise, it makes it harder for them to do that. In any situation, if you are improving value for your patients, you are helping them in ways that go beyond simply healing the injury.

Dr. Althausen: Value-based care is one of healthcare’s most often-discussed talking points. What kind of positive benefits has it brought in your experiences? What are some of the components that still need improvement?

Dr. Cunningham: Value-based care has transformed the way our community thinks about delivering orthopedic care. For the first time we are actually measuring how our patients are doing from their perspective with patient-reported outcomes while we simultaneously track the cost of care. We have taken a very qualitative process—recovery—and made it quantifiable. This has been rolled into cost which has historically been a black box, but new techniques, such as Time-Driven Activity-Based Costing,1 has created transparency around the cost to actually deliver care. These advances have set the table to measure and optimize the value of healthcare, and the field of orthopedics has become a leader in this arena.

Two very tangible benefits of value-driven care are, first, widespread adoption of patient reported outcome [PRO] data collection and analytics. Value cannot be measured without PROs and they have become the lynch pin for optimizing care. Second, the increased pressure on implant companies to increase competition and transparency around cost. This industry has existed on 500 percent plus margins for decades with little resistance. Value-driven care isn’t just for the physician; it must be collaborative with industry as well.

Dr. Eggers: In many offices I have worked in, the operating profit margin is thin. Thus, the ability to continue serving an ever-increasing number of patients is dependent on efficient utilization of scarce resources. I have seen small and medium practices grow and expand by focusing on value-based care. I have also seen many patients with limited ability to pay for their medical bills benefit from value-focused care delivery by giving them the same outcome with a lower cost.

I have seen a large amount of material and time inefficiency in orthopedic trauma—as well as healthcare in general—when the consequences of that waste are disconnected from the individuals making the decisions. The ubiquitous discussion and illustrated application of value-based care brings that concept to the forefront in the minds of decision-makers at all levels of the system, increasing the chance they will recognize an opportunity to save costs, improve outcomes, or both. Improvement in providing value-based care will come with an investment by all stakeholders. Even more improvement will come when the specifics of what entails value-based delivery are commonly known and become habitual.

Dr. Kelly: Value-based care has broadened my perspective on the duration and pathway of care that I choose for my patients. Treating people now means treating them in a way that accounts for potential clinical and/or economic pitfalls that could arise later. If we treat for long-term outcomes, there’s a lot of value in that. Reimbursement is the biggest component needing improvement to strengthen value-based care. There are a lot of strategies and initiatives hospitals use to drive down the cost of supplies, but in the end, it’s the doctor and the hospital, together, that must decide on when and how to maximize value.

Dr. Althausen: How has the pandemic impacted your ability to provide value and care for your patients? What long-lasting changes do you foresee in a post-pandemic orthopedic trauma environment?

Dr. Cunningham: The pandemic has had little effect on the orthopedic trauma landscape. We rotated weeks initially when the scope locally was unknown; however, it has basically resumed with business as usual. The primary change that may be long lasting is an increased footprint for telemedicine. It’s unclear if patients will accept this new route as concerns over the virus decrease, but certainly there has been a dramatic uptick in utilization over the last three months.

Dr. Eggers: The suspension of elective and non-emergent surgeries has had a large negative impact on the operations in the OR. With decreased revenue from fewer procedures, some staff were furloughed or laid off. The resulting loss of institutional knowledge made modifying materials and workflows to save time and money much more difficult. There was also a shift in focus from optimizing value-based care to learning, creating, and enforcing COVID-19 related protocols, so advances in care pathways were temporarily slowed.

Dr. Kelly: The pandemic, and the subsequent distancing we needed to implement to combat it, had us all re-thinking every aspect of our practices. Virtual health, telemedicine—the use of technology to meet with patients has been catalyzed by the pandemic and will be widely accepted going forward.

Dr. Althausen: What are some of the key elements that currently help you reduce the cost of care for your patients?

Dr. Cunningham: I could talk about this for hours. Here are a couple big principles: First, you have to pursue information and know how much your implants cost. This is, and always will be, the key driver of cost. It is the area where a surgeon has the most control and influence to make value-driven decisions. The second is with site of care delivery. More and more orthopedic surgery is being done in the ASC or outpatient setting—tibial nail, non-unions, etc.—and these can all be done safely outside the hospital setting. Finally, the other areas—such as durable medical equipment, physical therapy, and dressings—are all areas to influence cost.

Dr. Eggers: First and foremost in my experience: implants. Implants are one of the most consistent high-cost elements of orthopedic trauma surgery, which is why using high-value implants is one of the single best ways to decrease cost of care without compromising safety or outcomes. Other intra-operative measures include careful setup of preference cards, working with OR managers and sterile processing departments to optimize trays and packs, and limiting the number of disposable items used and opened. Surgeons should spend time learning the relative costs of different items and instruments so they can make an educated decision on whether or not a certain piece of equipment is necessary.

Dr. Kelly: At many points throughout the continuum of care for a patient, I question what is necessary to arrive at an optimal outcome. Are there unnecessary elements inflating prices that I can do away with? Those will be the first things to go. I want the best value in implants when an indication calls for implantables. Patients are completely overwhelmed when confronted with orthopedic surgery. My job is to provide stewardship for them. If they don’t ask about high-value implants, it doesn’t mean I shouldn’t use them. If implants have been clinically proven to provide the same equivalent outcomes attained by premium-branded ones, and they’re going to save my patient, my facility, and me a lot of money, then I’m using them, and that’s generally why I avoid using the branded implants altogether. There’s a better way to do it.