orthopaedic care shifts to outpatient and urgent care clinics
TRANSCRIPT
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Alejandro Badia, MD, FACS CEO/CMO, OrthoNOW LLC - Orthopedic Urgent Care Franchise
Hand & upper limb surgeon
Badia Hand to Shoulder Center
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Consumer oriented
Outpatient services expanding
Aging population
Bureaucracy/regulations paradoxically increasing
Automation/depersonalization
Less invasive (orthobiologics/ gene therapies…)
Healthcare changing drastically…
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Expensive
Inefficient
Redundant
Unpleasant
Unfriendly
Perfect Storm of Healthcare
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Ambulatory Surgery Centers
Diagnostic Centers
Retail Medicine
Urgent Care Centers
Medication Dispensing
Telemedicine and Mobile Apps
Cost effective shifts….
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National survey of Ambulatory Surgery in US (2006) 35 million amb surgeries, of which 20 million in hospital systems
Time spent: 146 minutes vs 97 minutes for free standing ASCs
GI scope, cataracts and spinal injections top 3 procedures
Approx. 6000 free standing ASCs . Driven by MDs as first one opened in early 70s by 2 physicians in Phoenix.
Medicare pays an ASC 55% of the fee paid to hospital outpt dept for same surgery. This number has continued to worsen….
Technological advances facilitate ability to do cases on outpt basis
Medicare and many carriers do NOT cover cost of implants at an ASC
Ambulatory Surgery Centers
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Specialty urgent care centers have similar goals as generalized entities Improved pt access Decreased cost Quality similar or superior to traditional ERs Specialty UC/ retail medicine can partner to
avoid hospital referrals Emphasis on multi-partner ambulatory system
Diagnostics ASCs Rehab facilities
Emerging Healthcare Entity
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General urgent care centers
Primary care walk in facilities
Retail walk-in clinics (MinuteClinic)
Pediatric urgent care
Cardiac/vascular urgent care
Ob/Gyn or Women’s urgent care ctrs
Orthopedic urgent care
Urgent care/walk in Healthcare
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Most musculoskeletal injuries are seen late in the game
Unless injury is open and/or severe, many orthopedic/sports injuries are shuffled between hospital, primary physician and urgent care centers long before the appropriate specialist is called in.
This is time consuming, expensive and frustrating (mostly for patient and providers)
The issue
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Long waits
Expensive (copays or full bill if uninsured)
Correct diagnosis may be missed
General urgent cares may not be adept at certain musculoskeletal injuries i.e. “Jammed finger concept”
Inefficient
Trainer/parent STILL has to take athlete to orthopedist for f/u or definitive treatment in most cases
Delay can adversely affect outcome and athletic performance
Current initial step can be modified/altered
Problem with current protocol
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Obtain timely emergency care
Maximize clinical result in order to regain premorbid level of function for athlete
Minimize costs and inefficiencies
Maximize communication to referral source (coach/trainer/supervisor/carrier)
All facets of treatment under one roof (outpatient)
Avoid litigation issues
Orthopedic injuries: dilemmas
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Involve the specialist early, preferably the subspecialist.
Allow that provider to order the appropriate tests NECESSARY to formulate treatment plan
Concept of a center is optimal for efficient and quality care • Accepts emergency visit from trainers, coaches, parents, ER and
general “urgent care”
• On-site radiographs, MRI, lab capabilities and creating an alliance with operating rooms is the ideal scenario. Therapy is beneficial as well so clinician can closely follow the recovery process and intervene early communicating with ATC
The Solution
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Cost-effective Healthcare needed
People frustrated with hospitals
Orthopedics has huge direct/indirect impact to society and costs
Increasing age of society
Major shift towards fitness - Crossfit - Triathlons - Gimmick Races - X-games mentality
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Business community recognizes cost benefits of prompt , high quality Orthopedic care….
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Physicians often receive blame for high costs/inefficiencies
Patients don’t understand R&D and regulatory challenges affecting medical device/pharma industries
Pts continue to feel that employers/insurers will “take care of them”
Frustrations misdirected. (lack of education to public/consumer)
Public perception issues
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Change ingrained culture of healthcare delivery
Acceptance by public/referral sources
Adoption of insurance (networks…..)
“AUTHORIZATION”
Disruptive Innovations in Healthcare
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Impingement commonly termed “bursitis”
Common in general population as well as sports world. Nuances to each group, however.
Rotator cuff tears and labral tears usually need repair and respond poorly to therapy /NSAIDs
Identifying this early saves time/money and can improve outcome
Clinical Example: Shoulder pain
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Physical exam, radiographs and MRI: 1 visit!
Dispense meds, begin Rehab or ARP neurotherapy, alter activity
Surgical problem: Arthroscopic procedure can scheduled first visit depending on clinical and imaging findings
Streamline evaluation process
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Terrible and nonspecific misnomer
May be one of many different pathologies PIP collateral ligament tear / dislocation Phalangeal fracture (articular?) Jersey finger Mallet finger Boutonniere Volar plate injury
Clinical Example: “Jammed Finger”
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Salvage procedure for delayed referral from urgent care center
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Severely crushed Middle phalanx base At PIP joint of finger
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Hamate graft From wrist in place With two screws
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Hamate bone from wrist
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rom Patient’s personal Facebook page
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Alternative protocol for care???
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Clavicle fx in surgeon/avid cyclist
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Pt fell in mountain bike trail.
He considered ER visit but his brother, another surgeon, recommended orthopedic urgent care, OrthoNOW
Seen within minutes, on a weekend, with subsequent x-ray images transmitted TO the appropriate subspecialist orthopedic surgeon, who happened to be lecturing abroad.
Pt. directly scheduled for procedure in adjacent outpt surgery center upon surgeon’s return.
Total time of assessment/decision making: 70 minutes
Next step: surgical plating at same facility: NO hospital
Seen at OrthoNOW Doral Saturday AM
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Patient missed no work after clavicle ORIF The surgeon shown here 72 hours after procedure!! Working…..
He attended OrthoNOW triathlon symposium 90 minutes (Fit Triathlete) after leaving OR#1 at surgery center at doral !! Sling and dressing in place…
Major procedures, including arthroplasty surgery (joint replacement) can be done safely in outpatient environment with good anesthesia/nursing team with less complications (nosocomial infections), hassle AND cost.
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Fast, efficient, and Precise orthopedic care With Less Stress, Less Wait And less Cost
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Orthopedic industry depends on clinician not end-user for product adoption
Involvement in healthcare delivery affects product/implant utilization
Patients increasingly becoming “Healthcare Consumers” not passive recipients
Hospital/Insurance domination beginning to shift
-Obamacare paradoxically leading to increase cost
-High deductibles takes insurance out of equation.
-Avoidance of expensive healthcare delivery (i.e. hospitals)
Ortho Industry/ Clinical synergies
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Educate patients and referral sources in network copays often similar to straight cash pay
Encourage specialty care (paradoxically the most cost effective)
Strengthen industry/clinician synergies (despite “Sunshine laws”)
Patients are consumers and free market system should prevail
Quality of care should influence cost and drive progress/innovation
Health insurance should be seen as “Catastrophic Care Insurance”
Cost savings would fund “safety net” for those patients in need
How to influence/benefit from shifts?
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