HealthLeaders Magazine—June 11, 2009
A severely arthritic knee or hip can be immobilizing and extremely painful, and in normal times, replacing the problematic joint can seem like a medical necessity. But as the economic recession has deepened, some patients have been rethinking elective surgeries, putting off expensive joint replacements until their finances are on surer footing.
In most cases, the surgeries are just postponed, not cancelled altogether. And the statistical and anecdotal evidence suggests the overall downtick in joint replacement surgeries has been very slight so far.
The market has grown in more ways than one. The sheer volume of aging baby boomers has boosted demand as more hips and knees wear out. On top of that, obesity related joint problems are becoming more common in an increasingly overweight nation. Yet demographics alone can't account for growth in the field. The market has expanded through process improvement, as well. Joint replacement surgeries have a near 95% success rate, and with very little risk, the decision has become easier for patients of all ages.
"In the past, you wouldn't do a hip replacement on anyone under the age of 65 or 70. People who were 50 who had problems were told to stick with it until they were old enough to do this. That doesn't cut it anymore because people don't want to be in chronic pain, so they are more willing to have procedures at a younger age," says Mark Figgie, MD, chief of the Surgical Arthritis Service at Hospital for Special Surgery, a 162-licensed bed orthopedic hospital in New York. "Part of that is driven by the fact that the surgeries are more predictable and more durable, so that's allowed us to expand the use of joint replacement into a younger population."
Volume of joint replacements at Hospital for Special Surgery grew 11% between 2007 and 2008, and that type of double-digit growth has been common, year-over-year, for hospitals across the country. The growth in many regions isn't slowing down, and experts predict it will speed up in coming years. More than half of patients needing hip and knee replacements are projected to be under 65 by 2016.
Most healthcare providers cringe at the thought of practicing assembly-line medicine. But if the analogy fits any sector of healthcare, it is joint replacement surgery. Despite the negative connotations of assembly lines in relation to healthcare, when it comes to manufacturing, assembly lines have many benefits - they can speed up a process, improve overall efficiency, and perhaps most important, reduce variability. The production process is broken down step by step, so that each widget is treated almost identically to its predecessors and successors.
Patients aren't identical, and neither are physicians, but reducing variability is an important goal for joint replacement centers looking to both improve quality and increase the volume of replacements that can be done in a given day. Patients aren't literally put on assembly lines, of course, but they can be assigned clinical pathways, predetermined care routines that can be put in place for about 80% of the population. It is essentially a planning process. Multidisciplinary teams regularly review the routine care steps for an average patient - everything from pre-op education to the surgery itself and the post-op recovery process - and develop best practices that are adhered to every time.
If the remaining 20% of the population with unique care needs is identified well before surgery, physicians can efficiently concentrate on targeted care for these outliers while maximizing the care process for the average patient. The distinction between the two groups often comes down to age, not just chronological, but physiological age as affected by obesity and other medical history factors. Identifying these people early can save money and time later in the process, says Douglas Padgett, MD, chief of the Adult Reconstruction and Joint Replacement Division at Hospital for Special Surgery.
"I know preoperatively who's not going to be able to go home right away. An octogenarian who lives in a six-floor walk-up in Manhattan... . is not going home, she's going to rehab. We try to identify those people early on in pre-op. It makes the process smoother, rather than on post-op day three or four trying to get in touch with a social worker," says Padgett.
Hospital for Special Surgery instituted clinical pathways in the 1990s primarily to reduce patient length of stay. At that time, the average patient would spend a week or more in the hospital after a major joint operation, but by 2008, the average length of stay was roughly four days. That hasn't all been from process improvements and variability reduction, however. Clinical improvements and advancements in the understanding of pain management have shortened the recovery time for a joint replacement, as well.
"The world is changing. Part of it is doctors' understanding of what the body can physiologically tolerate. In many respects, certainly in orthopedics, enhanced mobility is safer for patients. It's better to be up and moving," says Padgett. That means that medicating pain can actually have an adverse effect if it leaves a patient immobile and bed-ridden. The anesthesia department's pain management approach can make a big difference in a patient's ultimate recovery time.
One of the areas where it is absolutely essential for hospitals and physicians to be on the same page is device costs. Although volume and revenue have been on the rise, high margins aren't guaranteed in joint replacement surgery, in part because of challenges in controlling implant costs, which are perhaps the most significant controllable expense associated with the surgery.
Hospital for Special Surgery takes a bit of a hybrid approach. Leaders negotiate with vendors, often setting an appropriate price the hospital is willing to pay for a product - $11,000 for a hip, for instance. But instead of negotiating contracts that limit physicians' options, the hospital lets physicians choose any vendor willing to meet the bar.
"We get buy-in from the surgeons involved so we can, across the board, say you can use any device you want as long as the vendor you're working with meets this particular price," says Padgett.
For new developments - prototypes and technologies in the evaluation stage - the hospital takes a different approach. Before introduction, technologies are vetted at a subcommittee level and at a larger staff meeting to distinguish whether the vendor is repackaging an existing technology or genuinely offering something worth testing out.
"First question you ask," Padgett says, "is, does it need to be diamond studded and gold plated? Is it worthwhile? Do we want it here?"
Newer technologies that are approved are evaluated for about three years, at an initial vendor price. After that, they are reevaluated and the hospital gets a little more aggressive about prices.
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