How Oregon Surgical Institute made performing 70% of all total joint replacement volume in an ASC a reality

CMS added total hip arthroplasty to the ASC payable list on Jan. 1, a move that further perpetuates the migration of total joint replacement procedures from the inpatient setting to the outpatient setting.

While performing 70 percent of total joint replacements in ASCs may have been a fairytale 10 years, the recent success of many surgery centers could bring this once lofty projection into reality.

Total joint migration to the outpatient setting was the subject of an Aug. 13 session hosted by Becker's Hospital Review and sponsored by Regent Surgical Health.

During this session, two orthopedic surgeons discussed the formation of Beaverton-based Oregon Surgical Institute (OSI) as an orthopedic center of excellence in joint venture with Regent Surgical Health.

The speakers were:

  • Chris Nanson, MD, orthopedic surgeon and co-founder of Oregon Surgical Institute
  • Jim Ballard, MD, orthopedic surgeon and co-founder of Oregon Surgical Institute
  • Moderated by: Chris Bishop, CEO of Regent Surgical Health

Here's how OSI came to fruition:

1. OSI origins. When Drs. Nanson and Ballard co-developed OSI, they did so before CMS ever considered moving joint replacement procedures out of the inpatient setting. They had performed inpatient total joints and worked to develop a clinical pathway to improve outcomes. "We developed a strong hospital-program," Dr. Ballard said. "We had data, … and we were getting to the point where our average length of stay was getting into the same day. We evolved ahead of [the trend], saw what was being done and made the jump." They took their pathway to an ASC in town and performed same-day joint replacements successfully. After seeing notable results, they began discussing OSI. The decision foreshadowed an industry wide trend that continues to project large growth. For example, a recent study in the Journal of Rheumatology predicted that the total ASC total joint replacement volume in 2020 will triple by 2040.

2. The OSI pathway. Drs. Nanson and Ballard wanted a place to practice evidence-based medicine on their own terms. They recruited like-minded physicians and began a tedious meeting process around developing the surgery center. Collaboration was key. "[We asked] who's willing to give up a sacred cow?" Dr. Nanson said. "That was one of the ways we self-selected [our team.]" At OSI, a joint replacement isn't a standard joint replacement, it's either an OSI knee or an OSI hip. Surgeons follow OSI’s standardized pathway, which accounts for everything from soft costs to the implants used, to ensure optimal outcomes.

3. The OSI team. Early advocates for using orthopedic coordinators, Drs. Ballard and Nanson recognized the benefits of having a person accompany patients through the surgical process. When developing OSI, they reached out to coordinators they worked with in the past and asked if they'd come on board. They let the navigators work to the full extent of their license and assured them they'd have a seat at the leadership table. The process continued to anesthesiology. Just like how the center has a standardized pathway for a joint replacement, Drs. Ballard and Nanson wanted a standardized OSI method for anesthetics. They, once again, went into their past to bring in anesthesiologists they worked with, and just like with the coordinators, let them develop pathways that were best for the patient. Because of the high-functioning team, "our readmission rate is extraordinarily low," Dr. Ballard said. "... We spent the money, found the people and trusted them."

4. OSI's total joint journey. OSI was ready to capitalize when CMS' new total joint rules went into effect at the beginning of the year. While the reimbursement rate would have resulted in losses for the center, they knew they had to follow the trend. The OSI leadership team put out a request for proposal, found a quality vendor and pivoted their entire Medicare operation to that vendor and its implant. The change allowed the center to control costs further and turn Medicare into a profitable proposition. At the end of the day, OSI's success is "about putting the center above all our egos," Dr. Ballard said.

View a copy of this session here and learn more about Regent Surgical Health here.

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