A handful of topics dominated the conversation during the first educational collaborative hosted by the inSight Advisory – Clinical Performance team at HealthTrust, among them:

  • Knowing whether or not a medical device new to market warrants an upcharge
  • The shortage of clinical, utilization and trend data to guide decision-making and benchmark physicians
  • Uncertainty among administrators about how to initiate those conversations (physician engagement was the most requested topic for future collaboratives)
  • Physician readiness to partner with hospitals that are transparent with their financial data

The dinner event was held during the American Academy of Orthopaedic Surgeons (AAOS) 2017 annual meeting in San Diego, California. Guest speakers were HealthTrust’s Orthopedic Service Line physician advisor Gregory Brown, M.D., Ph.D. (St. Joseph Medical Center, Tacoma, Washington); HealthTrust physician advisor Craig Morrison, M.D. (Southern Joint Replacement Institute, Nashville, Tennessee); John Grady-Benson, M.D., (Connecticut Joint Replacement Institute at St. Francis in Hartford, Connecticut); and Lane Conger, director of strategic accounts for InVivoLink (HealthTrust, Nashville). Todd DeVree, HealthTrust’s director of bundled payment solutions, served as moderator.

Among the three dozen other attendees engaging in the lively discussion were HealthTrust CMO Michael Schlosser, M.D.; and HealthTrust orthopedic physician advisors Michael Gallizzi, M.D. (Porter Adventist Hospital, Denver, Colorado); Victor Hernandez, M.D. (University of Miami Hospital, Miami, Florida); Michael Kelly, M.D. (Hackensack University Medical Center, Hackensack, New Jersey); and Kevin Shea, M.D. (St. Luke’s in Boise, Idaho).

Focal points for the evening were six evidence-based topics, three each for total hip arthroplasty—highly cross-linked polyethylene (HXLPE) versus vitamin E-treated HXLPE, ceramic versus cobalt chrome femoral heads, and modular femoral neck components—and another three for total knee arthroplasty—conventional polyethylene versus HXLPE, patient-specific designs, and total versus unicompartmental knee arthroplasty. Clinical evidence, utilization trends and patient-reported outcomes (PROs) from the InVivoLink database were presented on each of these topics, followed by comments and discussion from the physicians on their process and reasons for selecting the components they utilize.

Data on the vitamin E-infused polyethylene was reported as a key learning of surveyed attendees. There is currently little evidence that vitamin E provides an improved wear rate relative to the alternatives and is also the most expensive of the three. In contrast, a cost-effectiveness analysis reports that premium technology (ceramic femoral heads and cross-linked polyethylene) do not change revision rates for patients over 75.

The practice of “demand matching” implants to patients based on their characteristics, such as age and expected activity, was woven into the presentation. Most surgeons informally do some level of demand matching already, in terms of choosing implants on a case-by-case basis. But the continued, sometimes imperceptible, influence of suppliers on those decisions remains problematic. Data from the Australian National Joint Replacement Registry indicates that plenty of “mature” implants have a failure rate of under 5 percent after 10 years, even as the pricy new models with no track record remain physician favorites.

Demand matching is nothing new, having fallen in and out of vogue several times over the past two decades. But the authorization of co-management agreements with surgeons under CMS bundled payment models (both voluntary and mandatory) has brought the concept back to the forefront. Hospitals have to meet certain quality standards as a condition of gainsharing, but the amount shared can be linked to their overall costs to CMS and/or internal costs. Co-management agreements are alternatively being used to incentivize physician alignment around demand matching with incentives that can run the gamut from a more relaxed call schedule to OR upgrades or a dedicated surgical scrub team.

Key takeaways for supply chain and service line administrators, both well represented at the event, included having surgeons lead conversations about implants and empowering them with both clinical evidence and financial data to make wise choices. Physicians at the dinner event highly recommended that hospitals be transparent with financial data, including both costs and margins, if they expect doctors to be true partners and align with hospital objectives. One suggested option was to set up a steering committee that focuses on the overall performance of the orthopedic service line and provides data on such things as individual surgeon performance, blood utilization, on-time starts, implant utilization and costs, and hospital financial performance for specific procedures.

Information Please

Physicians are clearly hungry for the data that guides their clinical decision-making. But under the best of circumstances, reaching a consensus about what’s best for patients—and therefore merits an upcharge—often isn’t easy. For example, there’s still much debate about whether cementless revision stems deserve a premium price even though they’re now the standard of care for total hip arthroplasty.

Another, more general problem is that hospitals don’t have a long history or a lot of experience in compiling evidence summaries for their physicians, or ranking its strength on a 1 (randomized controlled trials) to 5 (expert opinion and bench testing) scale. They’re also having a hard time tracking utilization and trend data for physicians within their own facility, let alone on a broader scale, to match against clinical findings (e.g., PROs).

Schlosser says a best practice at TriStar Centennial Medical Center in Nashville is to pull current scientific research findings and internal data discovery from the HCA Knowledge Center to facilitate informed discussions during monthly meetings of surgeons. Dr. Hernandez notes that the University of Miami Hospital forbids the use of technology unless it’s backed by a minimum of level 3 evidence (e.g., case control study).

The topic of demand matching will be revisited as an education session at the HealthTrust University Conference in Las Vegas in mid-July. The inSight Advisory – Clinical Performance team also has a demand matching tool and best practices for specific patient groups under development for surgeons.

by: Gregory A. Brown, M.D., Ph.D., Lane Conger, Todd DeVree and Anne Preston

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