How Greenville Health System created a cost saving care pathway for shoulder injury.
The emerging healthcare environment requires expanded patient access while minimizing the cost of care. This is of particular importance for accountable care organizations that are assuming significant risk and must develop more innovative ways to deliver care to drive better outcomes and wring out inefficiencies. Our practice has experienced this struggle on a daily basis as patients, who needed a surgical consult, were frustrated with limited access. Our clinical schedule was filled with non-surgical candidates. This created a paradox where the most specialized health system resources (e.g., surgeon and MRI) were being allocated to a continuum of care that did not result in better care or outcomes, while also increasing physician and patient frustration. The long-standing dilemma was that the wrong patient was often in the wrong clinic leading to an inefficient and circuitous path for the delivery of appropriate care. When evaluating our practice it was clear that we could improve our allocation of available resources with the outcome being happy patients and happy physicians within a healthcare system that was delivering high quality, low cost, appropriate care.
To achieve this outcome, we had to transition from a fee-for-service model into the emerging delivery and payment reform-based methodologies. We identified an opportunity to develop a clinically integrated system that can perform in today's fee-for-service model while at the same time providing a test case for future delivery and payment models. This care pathway is one that any ACO could also implement to save money. With this goal, we focused on one specific area: improving our orthopedic shoulder clinic efficiency by providing greater access to care while also increasing the surgical conversion rate.
We aimed to “flip the funnel” based on emerging research and our shared experiences in sports medicine and military medical service models. We felt that a better solution placed allied health professionals, in this case physical therapists, at the entry point of a clinically integrated team capable of decreasing patient burden in terms of satisfaction, productivity and cost, while improving patient outcomes and maximizing the surgical conversion rate. As our hospital partner, Greenville (S.C.) Health System, worked with us to implement this pilot program for high-value shoulder care, the goals of this program were to:
1. Improve patient access to a busy shoulder clinic;
2. Improve patient satisfaction by pairing the right patient with the right provider at the right time; and
3. Decrease cost by appropriately allocating manpower and expensive imaging resources.
Clinically integrated pathway for shoulder pain
We chose a diagnosis of shoulder pain based on Dr. Kissenberth’s expertise developed through his fellowship training in shoulder surgery with the Steadman Hawkins Clinics and the Hughston Clinic. Shoulder pain is second only to low back pain in terms of disability and cost, and impacts up to 20 percent of the population. Rotator cuff tears represent the most common diagnosis requiring a surgical opinion and affect 50-80 percent of those over the age of 60. Thus, we felt developing a shoulder pathway focusing on rotator cuff tears would address our immediate problem of patient access and clinical frustration while providing a basis to impact the overall value of healthcare.
The shoulder pathway uses best practice at the point of care to initiate an immediate treatment plan and limit specialized care unless warranted. When the patient’s history and physical examination suggest imaging is needed to confirm a rotator cuff tear, physicians use ultrasound at the point of care to provide real time diagnosis for the patient as opposed to waiting for an MRI. MRI and ultrasound are clinically equivalent for the diagnosis of rotator cuff tear with significant cost savings and convenience to clinicians and patients. Recent reports suggest every 1 percent conversion of MRIs to ultrasound can equate to $1 million in cost savings for the Medicare program and its patients. Not only does this clinically integrated pathway decrease costs by using ultrasound, it also provides the patient with a clear diagnosis at the point of care. This is in contrast to use of an MRI, which would result in a delay in diagnosis and return appointments for a clear prognosis and treatment plan.
The shoulder pathway also initiates either a physical therapy or surgical treatment plan based on this initial visit. Our process streamlines the patient encounter using a standardized treatment pathway based on their current disability, subsequent diagnosis and likely treatment prognosis. The plan is discussed and provided to the patient to facilitate an optimally informed treatment choice resulting in improved patient satisfaction. Patients who are indicated for surgery and post-operative physical therapy are able to be scheduled in a timely manner. Patients indicated for a conservative, physical therapy treatment approach usually receive a shoulder injection and anti-inflammatory medications. Then, patients are referred for an active rehabilitation program including both supervised and home exercises as well as hands-on manual therapy. In our program, 70 percent of patients resolve their pain and disability in 6 to 12 weeks without the need for an MRI. If patients don’t meet thresholds for improvement by four weeks, then the treatment plan is reassessed. To date, we are able to identify 90 percent of patients that are not responding to the conservative approach in less than five visits over a four-week timeframe thereby limiting unneeded care. To put this in context, this means that 70 percent of patients who would likely have gotten an MRI prior to the start of the pilot, are now able to resolve their shoulder pain for less than the cost of that one MRI. We also are able to reduce to a small number patients receiving therapy that did not contribute to resolving their complaints. This approach reflects a responsive, patient-centered healthcare system that achieves the two aims of optimal patient outcomes while also controlling healthcare costs.
The bottom line
Approximately 300,000 rotator cuff repairs are performed annually across the United States and this number reflects an increase every year since 1995. Conservatively, 60 percent of these procedures have a primary payer of Medicare with this number increasing rapidly given the aging population and the increasing surgical rates. Through our re-engineered clinical pathway, we are anticipating a 40 percent decrease in MRIs due to an exchange for ultrasound imaging concurrent with a 10 percent decrease in surgeries. Current reimbursement rates suggest a 75 percent savings for each patient that receives an ultrasound compared to MRI and a 90 percent cost savings for every patient that responds to the physical therapy course of treatment and avoids surgery. Additionally, this approach is likely to also result in cost savings as it removes the majority of non-operative patients from the surgeons’ schedule thereby increasing surgical conversion rates. Each patient gets specialized care.
The clinically integrated shoulder pathway as described above provides an efficient point of entry to care and follows best practice providing patients maximized healthcare value. We have been able to deliver better care to more patients by using the appropriately skilled provider at the right time and through first-line use of ultrasound instead of MRI. Increased access via the shoulder pathway provides a viable bridge from the current fee-for-service model to the forthcoming delivery and payment models we must be prepared to thrive under. Finally, due to patients receiving the right care at the right time, we are seeing greater patient satisfaction due to improved access and timeliness of treatment initiation. This clinically integrated model has allowed us to “flip the funnel” using a disruptive care model that delivers desired patient outcomes at a lower cost compared to usual care. We believe wider application of this novel clinical integration, using protocol-driven care across orthopedics is an effective strategy to improve physician efficiency and patient satisfaction in the emerging healthcare market.
Chuck Thigpen is a clinical research scientist with Proaxis Therapy and director of observational clinical research in orthopaedics with the Center for Rehabilitation and Reconstruction Sciences at the University of South Carolina. He holds adjunct appointments with Duke University Division of Physical Therapy, University of South Carolina Department of Physical Therapy, and Clemson University Bioengineering. He completed his PhD in Human Movement Science from the University of North Carolina-Chapel Hill in 2006.
Michael J. Kissenberth, MD, is the vice chair of clinical services of the Greenville Health System Department of Orthopaedics, as well as GHS Clinical Associate Professor of Orthopaedic Surgery, University of South Carolina School of Medicine. He specializes in sports medicine, arthroscopy, and complex reconstruction of the shoulder, elbow and knee. He is a graduate of The Citadel, where he captained the football team, and then attended the Medical University of South Carolina. He completed his residency in Orthopaedic Surgery at Tripler Army Medical Center in Honolulu, Hawaii, and served his fellowship in Sports Medicine with Steadman Hawkins Clinic of the Carolinas and the Hughston Clinic in Columbus, Ga.