Chesapeake Physician July/August 2016 Issue

chesphysician.comVOLUME 6 ISSUE 4 JULY/AUGUST 2016

Curbing PRESCRIPTIONPAINKILLERABUSE

InnovativeMEDICAREREIMBURSEMENT

Driving Better

JointREPLACEMENTS

Designing Better MEDICAL PRACTICE ENVIRONMENTS

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JULY / AUGUST 2016 l 3

CONTENTS

12 Driving Better Joint ReplacementsChesapeake-area orthopaedic experts discuss how data is driving changes in their approach, the pros and cons of minimally invasive hip arthroplasty and mid-term results for reverse shoulder arthroplasty.

18The Physician’s Role in Curbing Prescription Painkiller AbusePhysicians inadvertently contributed to the opioid epidemic. Now they must help reverse the problem.

F E A T U R E S D E P A R T M E N T S

6 CASES Advantages of Anterior

Hip Arthroplasty

8 SOLUTIONS Avoid Estate Planning

Mistakes With These

Essential Documents

24 HEALTHCARE DESIGN How to Design for Changing

Medical Practice Environments

29 POLICY Bringing Innovation to

Government Reimbursement

30 OUR BAY

ON THE COVER: Paul King, MD, orthopaedic surgeon and medical director, The Joint Center at AAMC.

4 l CHESPHYSICIAN.COM

Jacquie Cohen RothFounder/Publisher/Executive [email protected] @chesphysician

t seems that EHRs are finally generating

a worthwhile return on investment, at

least in terms of their ability to track and

improve healthcare outcomes through

data mining. Our cover story on better

joint replacements (p. 12) starts with a

segment on the work that a few of our

region’s leading orthopaedists are doing

to develop robust data that drives changes

in their orthopaedic practices, from PT-

assisted prehab exercises to

alternatives to femoral nerve blocks. The

American Joint Replacement Registry (AJRR), a national nonprofit data source for total

hip and knee replacements, is now providing valid and meaningful national comparison

data to help promote such changes across the country. Data is also influencing shoulder

procedures, with mid-term records demonstrating that reverse shoulder replacements are

superior to hemiarthroplasty for acute proximal humeral fractures.

With national attention focused on the opioid epidemic, it’s a good time to reflect

on the factors that fueled the crisis and the role physicians can play in ending it. Our

interviews with an emergency medicine physician and an interventional pain medicine

specialist offer some fresh perspectives on this topic (p. 19). These physicians provide

insight into their own approaches to limit use and abuse of potentially addictive

substances for treating pain. You can also read our previous articles on preventing

painkiller abuse at chesphysician.com.

Even the Centers for Medicare and Medicaid Services (CMS) is getting innovative,

with the launch of a new program called Comprehensive Primary Care Plus (CPC+),

that is expected to roll out in 20 markets around the country soon (p. 29). This program

offers up to 5,000 primary care physicians a patient centered medical home approach that

reimburses physicians for care management. The good news? Smaller physician groups

can be eligible for this model. The catch? A sufficient volume of providers in your area

must participate for you to be eligible.

This issue is also packed with advice for personal estate planning (p. 8) and more

efficient and patient-friendly healthcare design (p. 25), as well as a case study on anterior

hip arthroplasty (p. 6), which contrasts with the segment on the minimally invasive

posterior approach discussed in our cover story.

We hope you’ll be inspired by reading this issue as you enjoy the long days of summer!

To Life!

PUBLISHER’S NOTE

JACQUIE COHEN ROTHFOUNDER/PUBLISHER/EXEUTIVE EDITOR

[email protected]

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OPERATIONS MANAGER Stefanie Jenkins

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MANAGERSOCIAL& DIGITAL MEDIA

Jackie [email protected]

COPY EDITOREllen Kinsella

CREATIVE DIRECTORSusan Smerker

[email protected]

PHOTOGRAPHYTracey Brown, Papercamera

Jay Fleming, Jay Fleming Photography

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RANDY M. BECKER, MD Advanced RadiologyHARRY BRANDT, MD Sheppard Pratt Health SystemsPATRICIA CZAPP, MD Anne Arundel Medical Center HOLLY DAHLMAN, MD Green Spring Internal Medicine, LLCSTACY D. FISHER, MD University of MD Medical Center MICHAEL FREEDMAN, MD Evolve Medical Clinics JENNIFER MCQUADE, MD Virginia Hospital Center Physician GroupGENE RANSOM, JD, CEO Maryland Medical Society (MedChi) CHRISTOPHER L. RUNZ, DO Shore Health Comprehensive Urology VINAY SATWAH, FACOI Center for Vascular Medicine THU TRAN, MD, FACOG Capital Women’s Care

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I

DISCUSSION: Hip osteoarthritis is a common condition that many people develop during middle age or older. The most common symptom of osteoarthritis is pain around the joint. Decreased range of motion in the hip joint may cause a limp.

Although there is no cure for osteoarthritis, there are a number of treatment options to help relieve pain and improve mobility, including lifestyle modifications, physical therapy, assistive devices, and medication. Recommendations for surgery are based on a patient’s pain and disability, not his or her age. As the technology and the implants have improved, the hip replacement’s annual failure rate has fallen to between 0.5-1.0%.

There are multiple approaches to hip joint replacement: from the posterior (mini post), lateral, antero-lateral or anterior. Each approach has risks and benefits. Anterior (or direct anterior) hip replacement has been used since 1980, but over the past decade, it has become more popularized with the advancement in instrumentation and knowledge of hip anatomy. The benefits of different surgical approaches for total hip arthroplasty continue to be debated. Up to one year post-surgery, the direct anterior group demonstrated significant improvement

compared with the direct lateral group. At two years, results in both groups were the same.

Advantages of the anterior hip replacement procedure include:

1. It is performed in the supine position, while in other approaches patients may be in a lateral position, which is a non-physiologic position. This approach also may interfere with positioning of the implants.

2. In the supine position, the surgeon can use intra-operative fluoroscopy to recreate normal anatomy and recheck the implant’s positioning.

3. It is much easier to measure the length of the lower extremities and avoid limb-length discrepancy.

4. This approach uses the plane between the muscles, precluding the need to cut them. While the surgeon can repair muscles and tendons that are cut in other approaches, healing time and rehabilitation may be lengthened.

5. As the anterior approach is more muscle-preserving compared to other approaches, patients usually have less pain after the procedure and are able to engage in physical therapy sooner, possibly shortening length of stay.

6. The anterior approach is a true

minimally invasive surgery that is not based on the length of incision. Instead, the approach is based on cutting less muscle and detaching fewer tendons from bone. Patients have less pain, feel better and regain function faster, compared to other approaches.

7. With less soft tissue disruption, the precautions and limitations after surgery are minimal. There is no need for an elevated toilet seat or avoiding hip flexion greater than 90 degrees, as is typical of other approaches.

8. This muscle-sparing approach could decrease the chance of dislocation.

9. As the incision is at the front of the hip joint, patients do not experience pain from sitting on the incision.

10. As the muscles are preserved during the anterior hip replacement, the need for physical therapy is typically less than in other approaches.

The anterior hip replacement surgery offers considerable advantages to patients due to faster recovery, less post-operative pain and fewer restrictions. Our practice has found that we can perform a better and more accurate replacement surgery for our patients, that also appears to be more stable. Based on our results and patient feedback, the anterior hip replacement is the preferred approach for all of our primary hip replacement cases and the majority of our hip revision surgeries.

While the anterior approach for total hip arthroplasty is a tissue-sparing alternative to the traditional hip replacement and there are some early advantages to this approach, longer-term results may be similar when the implants are placed correctly. CP

Farshad Adib, MD, is assistant professor of Orthopaedic Surgery at the University of Maryland School of Medicine. He can be reached at [email protected].


CASES

Advantages of Anterior Hip ArthroplastyBY FARSHAD ADIB, MD

CASEFJ is a 57-year-old male who had bilateral hip replacement and needed a right hip revision arthroplasty due to acetabular osteolysis and multiple hip dislocations. After undergoing anterior hip revision arthroplasty, he was discharged to home one day after surgery and was able to return to his job less than 10 days post-operatively. FJ used narcotic medication for less than a week following his procedure. Despite the far greater complexity of the revision hip surgery, he noted that the procedure was much easier than his previous surgeries.

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HEALTHCARE MARKETING STRATEGIES

SOLUTIONS

Avoid Estate Planning Mistakes With These Essential DocumentsBY BRETT SAUSE


egardless of your level of wealth, failing to establish an estate plan can be detrimental to your family. A properly structured

estate plan helps ensure that your family and financial goals are addressed if you are incapacitated and after your death. Physicians should consider creating these documents for themselves.

Last Will and Testament A will directs your asset distribution

upon your death. Without a will, your property would pass as required under your state’s intestacy statutes. State law may not provide the inheritance scheme you would choose for your family, and could increase your exposure to federal estate taxes.

In addition to directing the disposition of your property, a will allows you to:

n Name an executor, avoiding the trouble and cost of a court-appointed administrator

n Avoid bonding costs n Avoid annual reporting/accounting to

the probate court n Name a guardian for minor children,

substantially eliminating the likelihood of a court-appointed guardianship

n Protect the children’s inheritances should your surviving spouse remarry

n Retain assets in trust if distributions to your heirs at your death would be inadvisable

For high-net-worth married couples, a will may also assure that federal estate tax benefits are preserved for their estates, allowing them to take full advantage of the unlimited marital deduction and the federal estate tax exemption ($5.45 million per individual in 2016) of both spouses. Allocation of the first-to-die spouse’s exemption amount to a trust may reduce estate tax for the couple’s

combined estate, provide asset protection and allow control and management by a trustee, while still benefitting the surviving spouse and children.

For couples with more modest estates, estate tax-efficient wills may be less advantageous from a total federal tax perspective than an “all-to-spouse” will, taking into consideration the unlimited marital deduction, the potential portability of a deceased spouse’s unused “applicable exclusion amount” and the opportunity to have appreciated assets receive a step-up in tax basis at both spouses’ deaths (possibly reducing the heirs’ capital gains tax).

Revocable Living Trust A revocable living trust (RLT) is an

arrangement that allows the grantor to transfer ownership of property into a trust during one’s lifetime. An RLT can be used as a substitute for a will by distributing assets upon the grantor’s death. Unlike a will, a revocable living trust serves as a ‘rulebook’ that can govern the distribution and use of the trust assets during the grantor’s lifetime, making it a useful planning tool if the grantor becomes incapacitated. Benefits may include:

n Avoidance of probate for assets owned in an RLT, which bypass the probate process, potentially enabling a faster, less costly asset transfer than a will. An RLT also can help avoid multiple probate proceedings when property is owned in multiple states.

n Privacy preservation – unlike a will, where asset transfers may become public, trusts allow asset transfers to remain private within the constraints of the trust document.

n Segregation of assets for couples with substantial separate property acquired

prior to the marriage, in community property states.

n Estate tax minimization at death.

Durable General Power of Attorney A power of attorney allows a person

(principal) to appoint another person or organization (agent) to handle their affairs when they are unavailable or unable, granting the agent limited or broad powers as specified in the document to manage the principal’s finances and property.

Healthcare Power of Attorney This document allows the principal to

designate an agent with authority to make healthcare decisions on their behalf if they are rendered unconscious, mentally incompetent or unable to make decisions.

A HIPAA authorization allows medical providers to release a patient’s protected medical information to another person. Individuals may include the HIPAA language in the Health Care Power of Attorney, or may use a freestanding document.

Living Will/Advance Directive A living will, or advance directive, is a

legal document that makes known one’s wishes regarding life-prolonging medical treatments. It does not become effective unless the declarant is incapacitated.

While physicians often witness the negative impact of failing to create these important legal documents, they can neglect putting their own affairs in order. Ensure that you take the necessary legal steps to protect yourself and your family. CP

Brett M. Sause, LUTCF®, LTCP®, CLTC®, RFC®, principal & CEO, Atlantic Financial Group, LLC. He can be reached at [email protected].

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BY LINDA HARDER PHOTOGRAPHY BY TRACEY BROWN

What began 40 years ago in the Annapolis area as the Orthopedic and Sports Medicine Center has evolved to become Anne Arundel Medical Group Orthopedic and Sports Medicine Specialists (OSMS), part of the network of specialty practices owned by Anne Arundel Medical Center (AAMC).

The practice includes 17 board-certified orthopedic surgeons who provide progressive orthopedic care to the residents of central Maryland and the Eastern Shore. OSMS’s five locations – in Annapolis, Bowie, Millersville, Odenton, and Pasadena – provide on-site imaging and rehab services that include X-ray, physical therapy (PT), occupational therapy, casts, splints, and orthotics.

“We have a long history of innovation,” says Jeffrey Gelfand, MD, OSMS medical director. “Our founders realized early on that the future of orthopedics lay in subspecialty care, hiring fellowship-trained sports medicine and foot and ankle specialists long before this was the norm.”

Today OSMS physicians have advanced training in subspecialties that include foot and ankle, knee and hip, hand, elbow and shoulder, spine, total joint reconstruction, arthroscopic and microvascular surgeries, sports medicine, pediatric disorders, bone and joint disease, arthritis, fractures, and emergency trauma. OSMS also has on-staff physiatrists, a podiatrist, physician assistants, and certified nurse practitioners.

Same-Day Access for General and Spine OrthopedicsRecognizing the need to offer fast-access appointments for

non-life-threatening, acute orthopedic injuries, OSMS recently opened two OrthoTODAY locations in Annapolis and Pasadena. “The concept has been so popular that we’ve added SpineTODAY for fast-access appointments for patients with urgent back problems,” says Dr. Gelfand.

“Patients with orthopedic injuries appreciate seeing orthopedic specialists quickly rather than being exposed to other illnesses in an urgent or emergent setting,” he adds.

Sports Medicine Gets Athletes Back in the GameIn addition to OrthoTODAY, Dr. Gelfand says OSMS offers

one of the largest sports medicine programs in the state. Physical therapy and rehab are an integral component of the sports medicine approach, with PT departments in every practice location.

A robust research program underpins the practice’s approach to sports medicine. “We offer runners a gait analysis program based on sophisticated data analysis, and we treat running injuries with the latest protocols,” says Dr. Gelfand.

Hip arthroscopy is emerging as one of the newest minimally invasive orthopedic procedures to treat a variety of conditions, including labral tears, hip impingement, articular cartilage injuries, and loose bodies.

AAMG’S ORTHOPEDIC AND SPORTS MEDICINE

SPECIALISTS:

Expanding the Breadth

and Depth of Orthopedic Innovation

Jeffrey Gelfand, MD


“We have one of the only fellowship-trained hip arthroscopists in the entire Mid-Atlantic region,” Dr. Gelfand comments. “He offers arthroscopic treatment of femoroacetabular impingement and advanced labral reconstruction and repair techniques.”

Outcomes and Innovation Drive ResultsOSMS physicians have devoted their lives to the study of

orthopedics and the treatment of musculoskeletal trauma, sports injuries, degenerative diseases, and congenital conditions. Teaming up with the AAMC Research Institute, they have embraced the collection and analysis of data to improve outcomes in every aspect of orthopedic practice.

“OSMS surgeons are the core of the team at The Joint Center at AAMC, the busiest joint program in Maryland,” says Dr. Gelfand. “Our patient satisfaction scores have been in the top five percent of the nation over the past five years, highlighting our commitment to excellence.” You can find more information on AAMC’s hip and knee joint outcomes at AAHS.org/Joint/Outcomes.

“Our research has helped us develop a high-volume program, with stellar outcomes, all the while offering this care at one of the lowest costs in the state,” adds Dr. Gelfand.

Research activities drive innovation as OSMS continually searches for opportunities to improve patient care, including clinical trials, the addition of dedicated research fellows and publication in national journals.

Studies have shown that higher-volume joint programs often lead to better outcomes, and OSMS performs high volumes of shoulder, ankle, knee, and hip replacements.

“We’re now expanding our outcomes research to sports medicine, upper extremity and spine,” says Dr. Gelfand.

“Our practice is the best-kept orthopedic secret in the state,” he concludes. “We offer a unique combination of highly trained skilled clinicians, a culture of innovation and outcomes-oriented practices that are fast making us an orthopedic hub for the entire region.”

OSMS Grows Osteoporosis Education and TreatmentSo what’s next for a practice that prides itself on continued

growth and improvement? Dr. Gelfand says OSMS is expanding its focus on osteoporosis education and treatment.

As osteoporosis becomes an increasingly prevalent disease among our aging population, OSMS realizes its orthopedic surgeons often may be the physicians best positioned to diagnose and initiate appropriate treatment.

OSMS is one of only two practices in the state to be named a star performer by the American Orthopaedic Association’s Own the Bone post-fracture quality improvement initiative, which recognizes programs that prevent future fractures in fragility fracture patients.

A Trusted Community PartnerOSMS continually looks for ways to help educate the

community. For the past seven years, OSMS has run a youth

sports injury prevention conference in February that serves regional high school sports teams. Also, every June the practice is part of a group that offers hundreds of free sports physicals to area high school athletes.

To promote innovative orthopedic practices, OSMS also hosts area orthopedists, primary care physicians, physical therapists, and athletic trainers for a one-day continuing education conference called Emerging Concepts in Orthopedic Surgery (see sidebar). For more information on OSMS, visit askAAMC.org/OSMS or call 410.268.8862. CP

Emerging Concepts in Orthopedic Surgery CME ConferenceHosted by AAMG Orthopedic and Sports Medicine Specialists

Saturday, October 15, 2016Anne Arundel Medical CenterRegistration: 7:30 am Conference: 8 am-4:30 pmRegistration Fee: $200 Early Bird Fee $175 until August 30

This one-day course is targeted to orthopedic surgeons, primary care providers, physician assistants, nurse practitioners, physical therapists, certified athletic trainers, nurses, and other allied professionals who want to learn about emerging treatment options for common conditions encountered by orthopedic surgeons. The course includes lectures on upper extremity conditions, ankle and knee replacement surgery, spine surgery, and sports medicine injuries. The format includes lectures, breakout sessions and surgical demonstrations broadcast from Anne Arundel Medical Center’s Simulation to Advance Innovation and Learning (SAIL) Center.

COURSE TOPICS INCLUDE:

• How to do a patellofemoral replacement• The current state of treatment of acute scapholunate ligament ruptures• Global sagittal spinal alignment • Operative management of the stiff elbow• Indications and contraindication for dry needling• New frontiers in arthroscopic repairs in the hip• Exercise induced compartment syndrome, a mysterious malady• The evolving use of ankle replacement• Benefits and features of the trochanteric fixation nail (TFN)• Enhanced recovery after joint replacement at AAMC• 3D printing in orthopedic surgery

To register or learn more, visit AAHS.Cloud-CME.com/EmergingConcepts2016 or call 443.481.5555.Continuing Education (CME 8.0)


Driving Better

BY LINDA HARDER PHOTOGRAPHY BY TRACEY BROWN

Using Data to Improve Joint OutcomesWith hip and knee replacements on the rise – over seven

million Americans have undergone these procedures – and a growing emphasis on data to measure cost and quality, and ultimately reimbursement, it is becoming imperative for orthopaedists to benchmark their outcomes.

Joint registries demonstrate up to a 50% reduction in revision rates after registry initiation and identification of best practices. One estimate is that CMS could save over $65 million if U.S. hip and knee revisions were cut by just 2%. The American Joint Replacement Registry (AJRR), a national nonprofit data collection organization for total hip and knee replacements, has emerged as a valid source for actionable outcomes data comparisons that are driving changes in practice.

To date, nearly 700 hospitals and 5,000 surgeons are participating in AJRR, which has collected data on over 375,000 hip and knee procedures. The AJRR began as a Level I data registry focused chiefly on patient demographic and procedure information. Starting November 2015, participants have been able to submit Level III patient-reported outcome measures (PROMs). AJRR recommends four patient-reported outcome measures – HOOS JR. (Hip disability and Osteoarthritis Outcome Score Jr.), KOOS JR. (Knee disability score), PROMIS-10 Global (a 10-item tool that measures symptoms, functioning and quality of life), and VR-12 (The Veterans RAND 12-Item Health Survey).

CREATING AN OUTCOMES PROGRAM

Paul King, MD, orthopaedic surgeon and the medical director, The Joint Center at Anne Arundel Medical Center (AAMC), describes the evolution of PROMs at his institution over the years. He recalls, “Since I became the director in 2009,

CHESAPEAKE-AREA

ORTHOPAEDIC EXPERTS

DISCUSS HOW DATA IS

DRIVING CHANGES IN

THEIR APPROACH, THE

PROS AND CONS OF

MINIMALLY INVASIVE HIP

ARTHROPLASTY AND

MID-TERM RESULTS FOR

REVERSE SHOULDER

ARTHROPLASTY.

JointReplacements

Paul King, MD,

orthopaedic surgeon,

medical director, The

Joint Center at AAMC



we’ve worked on creating our own outcomes program using internal resources, and creating a final good working product in 2011. As the AJRR has become more sophisticated this year, we started using it.”

Dr. King’s department started by using EPIC to provide basic demographic and laboratory data on patients undergoing hip and knee replacements. They also used surgeon-reported data and patient-reported outcomes from the Knee Society Scoring System, the Harris Hip Score (which surveys patients about pain severity and its effect on activities, function, range of motion, etc.), HOOS and KOOS.

He recalls, “We collected so much data that, at the time, our IT expert could hardly run it all.”

Dr. King continues, “Today, everything we do is data driven. With data from thousands of hip and knee replacement patients, we can evaluate and modify our practices for better outcomes. We have a research fellow and have published papers and presented at various orthopaedic meetings. At the Pennsylvania Orthopaedic Society, for example, we presented a study comparing quality of life after two types of hip replacement, and we made a presentation at the American College of Surgeons last year regarding length of stay and complication rates. We recently published a paper looking at which medical comorbidities prevented earlier discharge after hip replacement.”

DATA DRIVES PRACTICE CHANGESOne of the findings from the data that surprised Dr.

King and his colleagues was why people returned to the emergency department (ED) after joint replacements. “We found that over 30% of ED visits were due to swelling, which typically doesn’t require emergency intervention. When patients are not appropriately educated, they don’t do as well. As a result, we have improved both patient access and patient education.”

Data also demonstrated that outcomes improved when a PT assisted patients with prehab exercises, compared to simply handing patients a list of exercises. Dr. King explains, “In April, we started a program where our PT goes to the patient’s house prior to surgery to evaluate the home. They also visit several times after surgery to ensure that post-op recovery is progressing.”

Data from March 2014 to May 2016 showed that the number of patients going to a rehab facility after arthroplasty dropped from 29% to 17%, thanks to better prehab, starting many patients with therapy and walking the same day that they have surgery, modifications to anesthesia and pain control regimens, and nurse navigators. CMS doesn’t approve reimbursement for rehab stays based on social or home factors, but those factors significantly affect a patient’s recovery.

David Romness, MD, an orthopaedic surgeon with OrthoVirginia and medical director of the Joint Replacement Center at Virginia Hospital Center


“From 2014 to 2016, we increased from 9% to 43% the number of patients undergoing hip and knee arthroplasty who left the hospital with a one-night stay,” Dr. King notes. “As we improved the process based on data, our readmission rate also decreased 40%.”

To assist with these rapid recovery initiatives, AAMC hired two nurse navigators who meet patients before surgery and are available weekdays to assist patients throughout the process. After business hours, patients can call the hospital’s Ask a Nurse line, available 24/7.

“It’s critical to catch problems with prostheses early and not have to wait for results from smaller countries with well-established joint replacement outcome registries,” reflects Dr. King. “When we look at the HOOS data, for example, we can look underneath the big questions for actionable data. It’s awesome.”

He adds, “We learned from the data that the femoral nerve block helped with pain control but inhibited the quadriceps, delaying early ambulation in some patients, so we moved to an alternative pain control approach. OR practices have changed to use spinal anesthesia almost exclusively over general because patient recovery appears to be superior in appropriate patients.”

Dr. King states, “We have monthly multidisciplinary team meetings and the data helps guide our decisions. The culture here has really switched and people today embrace the data. I refer my patients to other specialists who are collecting data and advise other physicians to do the same.”

He notes that, whereas hospitals performing over 100 hip or knee arthroplasties annually used to be considered high volume, today performing over 1,000 joint replacements has been shown to improve outcomes. Physicians and patients should look for centers with transparency about their volumes and experience.

Minimally Invasive Posterior Hip is “Routine”For David Romness, MD, an orthopaedic surgeon with

OrthoVirginia in Vienna, Va., and medical director of the Joint Replacement Center at Virginia Hospital Center, minimally invasive (MIS) posterior hip replacements are routine. “We started about 17 years ago doing these procedures after one of our residents asked why we weren’t using an MIS approach,” he recalls.

“In our national orthopaedic meetings, orthopaedists report that the results between MIS posterior and the anterior approach are similar, so I recommend that patients have their surgeon perform the procedure they have the most experience with,” he advises.

The anterior approach has the potential advantages of lowering dislocation rates and avoiding hip precautions. It also has several potential disadvantages, including a higher complication rate; the need for a special Hana table, longer set-up and OR time; and greater expense.

MIS POSTERIOR APPROACH ADVANTAGESAdvantages of the MIS posterior approach can include:n Ability to split the gluteus maximus muscle without

removing the entire tendon, minimizing repairn No injury to lateral femoral cutaneous nerven Under 1% risk of sciatic nerve injuryn Reduced fracture risk n Direct visualization of hip cup and femur n No need for intraoperative X-rays

Dr. Romness comments, “The MIS posterior approach also has a decreased incidence of blood transfusions. I can’t remember the last time we transfused a patient.”

PATIENT SELECTION“Almost any patient can be a candidate for either the

posterior MIS approach or the anterior approach – it depends more on the surgeon’s preference and experience.” Dr. Romness notes, “We’re getting stricter about body mass index (BMI); a BMI of 40 is now my upper limit, and Kaiser Permanente has a limit of 35. Patients must also have their diabetes under control before surgery. Obese patients have a seven to eight times higher rate of infection and diabetics have two to three times the rate.”

PROTOCOLS, PAIN MANAGEMENT SPEED RECOVERYDr. Romness has found that the rehab protocol and pain

management approach selected can make a significant difference in outcomes. “People claim that the anterior approach has a faster recovery time, but when we changed our rehab protocol, we found we can get equal recovery results with the MIS posterior approach. We get patients up the day of surgery and have them perform full weight bearing day one.

“Appropriate pain protocols are key to a successful recovery,” he continues. “To address multimodal pain pathways, we give patients a pre-op ‘cocktail’ that includes pain medication, an anti-nausea drug and nerve relaxant – typically Celebrex®, Oxycontin, Zofran, and Lyrica®.”

During surgery, his pain protocol includes a spinal anesthetic and EXPAREL®, a liposome injection of bupivacaine into the surgical site to produce post-op

People claim that the anterior approach has a faster recovery time, but when we changed our rehab protocol, we found we can get equal recovery results with the MIS posterior approach. – DAVID ROMNESS, MD


analgesia. Following surgery, he says, “We use non-narcotic pain medication as much as possible and we rapidly get patients back on their feet.”

IMPROVED HIP ARTHROPLASTY MATERIALS Dr. Romness notes, “The basic design of hip prosthetics

hasn’t changed in about 20 years, but the materials are much better today. There’s no more metal-on-metal. For patients over age 65, I highly recommend a metal ball and a cross-linked polyethylene socket; for those under 60, a ceramic ball on a cross-linked polyethylene socket is preferred; and for those 60 to 65, the choice of materials depends on their preference and activity level.”

Lab studies have shown that ceramics produce less wear 20 years after the hip replacement, but a slight risk of breakage that is lowered with today’s newer materials.

MIS POSTERIOR TECHNIQUEIn the MIS posterior approach to hip arthroplasty,

surgeons make an 8- to 12-inch incision that partially releases the attachment of the piriformis and superior gemeli muscles, two of the four external rotators of the hip. The joint capsule is opened and retained, then it and all muscle layers are repaired at closure.

Dr. Romness observes, “The total procedure time is less than one hour.”

Life-Changing Reverse Shoulder Arthroplasty

The reverse shoulder replacement approach, in which the normal socket and ball anatomy of the shoulder are ‘switched’ so that a metal ball is fixed to the socket rather than the humerus, was pioneered in Europe in the 1980s. Appropriate for patients with large rotator cuff tears and resulting arthropathy because it relies on the deltoid muscle rather than the rotator cuff, it was not FDA-approved in the U.S. until 2003.

Bruce Knolmayer, MD, is an orthopaedic surgeon with the MedStar Georgetown Orthopaedic Institute who performs surgery at its MedStar Montgomery Medical Center location. He notes that three primary indications tend to drive the selection of reverse shoulder replacement:

n Patients with severe arthritis in their shoulder who have a torn/non-functioning rotator cuff

n Patients with a significant fracture of the proximal humerus

n Patients with a chronic shoulder dislocation or with a standard shoulder replacement that has dislocated

Bruce Knolmayer, MD, orthopaedic surgeon at MedStar Georgetown Orthopaedic Institute


Dr. Knolmayer states, “Candidates tend to be age 65 or older who have ‘worn out’ their rotator cuff. Many had a torn rotator cuff for years prior to the procedure, which led to severe arthritis and significant functional impairment, to the point where they often can’t put on a shirt or feed themselves easily.”

Reverse shoulder replacements remain far less common than hip or knee replacements - Dr. Knolmayer estimates he has performed about 30 of these procedures in the past four years, compared to more than 400 hip/knee replacements during this same time. He notes, “It adds to the continuum of care options we have and most impressively, it restores significant function to these patients, improving their quality of life.”

MID-TERM RESULTS PROMISINGIn the 13 years since the procedure’s approval here,

mid-term results are now available, but long-term outcomes are still to come. A study published September 2014 in the Journal of Shoulder and Elbow Surgery by Evan Lederman, et al, demonstrated good mid-term results. A May 2015 article in the Journal of Bone and Joint Surgery by Lawrence Gulotta, MD, reported that reverse shoulder arthroplasty provided superior functional outcomes compared to hemiarthroplasty for acute proximal humeral fractures.

“Most reverse shoulder replacements are expected to have a 10- to 15-year survival rate,” explains Dr. Knolmayer. “The short- and mid-term results of these reverse shoulder replacements are very promising, but we don’t yet have the long-term results to show that they can be implanted into younger patients.

“Patients need good bone stock around the joint,” he adds. “If the glenoid is small or deficient to start with, it makes the first procedure more difficult and we may not be able to do another procedure down the road when the first replacement one wears out. Even the European data is limited regarding revision procedures. The possibilities include reconstructing with cadaver bone or not replacing the socket in the second operation.”

However, societal changes and increased activity in the aging population today mean the indications are moving toward younger patients.

“I do my best to treat patients conservatively as long as possible and follow the American Academy of Orthopaedic Surgeons’ guidelines. In younger patients with an intact rotator cuff, the standard shoulder replacement is typically appropriate.”

Complications are increased in patients with morbid obesity, a history of smoking or diabetes, leading to increased infection rates. Preoperatively, a patient must have

good blood sugar control and those on immunosuppressants such as Enbrel and methotrexate must be taken off of them to allow adequate wound healing.

THE REVERSE SHOULDER PROCEDUREDr. Knolmayer states, “The two approaches to shoulder

replacements haven’t changed much and the technology hasn’t changed much in the past decade.” Computer-assisted procedures still have no place in shoulder replacements. Data suggests that even in knee replacements, robot-assisted outcomes are no better and are more expensive.”

Dr. Knolmayer notes that, prior to surgery, he orders three to four X-rays for most patients, ordering a CT scan only to resolve any ambiguous findings. “The problems usually are in the socket and we need to determine the adequacy of the bone. We also sometimes order MRI if we cannot otherwise determine if the rotator cuff is torn.”

He adds, “Pre-op strengthening programs have gained favor. Medicare only allows for a limited number of rehab visits, so we don’t want to use those up prior to the surgery. Patients also attend a pre-op seminar one to two weeks before the procedure, where they are oriented to the unit and learn what to expect during and after surgery.”

The average length of stay is two days. “There’s a push for overnight surgery but it’s not an outpatient procedure yet,” notes Dr. Knolmayer. “Patients wear a sling for three to four weeks, chiefly for comfort, and should not drive for six to eight weeks.”

A common complication with reverse shoulder replacement is dislocation. Patients are instructed not to put their arm behind their back or push off from a chair with the arm for three months following the procedure.

“Reverse shoulder patients are thrilled to raise their arm above their head for the first time in years,” Dr. Knolmayer concludes. “We primarily are relieving pain, but the functional increase is impressive.” CP

Paul King, MD, orthopaedic surgeon and medical director, The Joint Center at Anne Arundel Medical Center

David Romness, MD, an orthopaedic surgeon with OrthoVirginia in Arlington, Va., and medical director of the Joint Replacement Center at Virginia Hospital Center

Bruce Knolmayer, MD, an orthopaedic surgeon with the MedStar Orthopaedic Institute who performs surgery at its MedStar Montgomery Medical Center location

Reverse shoulder patients are thrilled to raise their arm above their head for the first time in years. — BRUCE KNOLMAYER, MD



THE PHYSICIAN’S ROLE IN CURBING PRESCRIPTION PAINKILLER ABUSE

t’s difficult to tune to any talk radio station, pick up any newspaper or flip to any news channel without running into a discussion of the horrific toll of prescription painkiller abuse. City, state and federal governments and numerous provider organizations are all working to stem the rising tide of abuse and overdose deaths. They are proposing new guidelines and additional funding for everything from making Naloxone more available to encouraging over half a million providers to complete opioid prescriber

training in the next two years.In recent years, drug overdose has overtaken other

causes of accidental death in the U.S., causing more than 47,000 deaths in 2014 – nearly 19,000 from prescription painkillers and over 10,000 from heroin overdoses. Roughly 80% of heroin users started out abusing prescription painkillers, and the number of deaths from heroin quadrupled from 2000 to 2013. The CDC estimates that for every death from overdose 130 people abuse painkillers. In 2012,

Physicians inadvertently contributed to the opioid epidemic. Now they must help reverse the problem.BY LINDA HARDERI


providers wrote enough prescriptions for opioids to equip every American adult with their own bottle of pills.

ROOT OF THE OPIOID EPIDEMIC

Some blame the FDA’s approval of OxyContin®, an extended-release formula of oxycodone in 1995, followed by approval of an 80-mg version in 1996 and a 160-mg version in 2000, with fueling the current crisis. The manufacturer, Purdue Pharma, heavily marketed the drug to healthcare providers, increasing sales 2,000% in just four years. In 2007, the company paid $600 million in fines and fees for misleading physicians by claiming the drug was less likely to be abused than other opioids.

Vanessa Redd, MD, an emergency medicine

physician with Emergency Medicine Associates at Carroll Hospital in Westminster, Md., states, “The root of the problem is multifactorial. A trend in the 1990s to objectively define pain came around the same time as explosive growth within the pharmaceutical industry and surveys of patient satisfaction regarding pain control. High-potency opioids that were initially reserved for conditions such as malignancies were then rapidly expanded to other diagnoses.”

Fortunately narcotic prescriptions are finally on the decline. The number of prescriptions rose from 76 million in 1991 to a peak of 219 million in 2011, then declined to 207 million by 2013. “Hopefully, that downward trend will continue, especially with a concerted effort by physicians, specialty organizations and hospitals,” says Dr. Redd. “We’re seeing increased physician awareness in social media and medical literature.”

The Maryland Hospital Association (MHA) guidelines, created in concert with the Maryland chapter of the American College of Emergency Physicians (ACEP), calls for renewed efforts on a number of fronts (see sidebar). Among the guidelines is the recommendation that painkillers like Oxycodone be prescribed for three days or less – without a refill – and that only acute pain be treated with opioids. States Dr. Redd, “As we all become more consistent, it helps everyone, because patients hear the same messages from all of their providers.”

A DILAUDID-FREE ED

As one important step, hydromorphone hydrochloride (Dilaudid), one of the strongest opioids, is no longer stocked in Carroll Hospital’s Pyxis. “In December 2015, our ED became Dilaudid-free, though we still use it for select conditions such as terminal cancer or poly-trauma,” explains Dr. Redd. “While we were afraid that patient satisfaction and pain scores would decline, they’ve actually improved since we started using appropriate dosing of morphine in its place. Certainly, we want to effectively treat pain, and there are lots of safer options.”

She continues, “Dilaudid produces a significant and potentially addictive ‘high’ compared to morphine. Also, one mg of Dilaudid equals eight mg of morphine; since one mg sounds small, it predisposes to overdosing. We’re also less likely to immediately use Dilaudid when patients believe they have allergies to other opioids; we now ask what their reaction is – if they are lightheaded or nauseous, that’s a side effect, not an allergy.”

Studies have shown that NSAID’s are as effective as

opioids in many cases.— VANESSA REDD, MD

MHA /ACEP Guidelines*

To reduce the likelihood of abuse, MHA/ACEP Guidelines call for ED providers to:

1. Screen for substance misuse, conduct brief intervention and give referrals to treatment programs for patients at risk.

2. When possible, consult PDMP before writing an opioid prescription.

3. Use data from CRISP, Maryland’s Health Information Exchange.

4. Attempt to notify the primary opioid prescriber or primary care provider in cases of acute exacerbation of chronic pain.

5. Not provide prescriptions for controlled substances that were lost, destroyed or stolen, or methadone or buprenorphine for patients in a treatment program, without verification.

6. Not prescribe long-acting or controlled-release opioids unless clinically indicated.

7. Counsel the patient about steps to prevent opioid abuse.

8. Prescribe no more than three days of opioid analgesics for serious acute pain.

*Adapted from the published guidelines


RED FLAGS OF ED ABUSERS

Patients who have multiple ED visits in a short timeframe, have a complaint not supported by their clinical data, or request specific medications or doses raise a red flag; patients who get angry or ‘bargain’ for certain medications should also prompt screening for abuse. Dr. Redd notes that most patients are amenable to trying a non-opioid pain reliever, when asked to try that before turning to an opioid.

PROVIDER COORDINATION

AND CASE MANAGEMENT

Coordinating pain care with other providers and using case management also addresses abuse. “We have a great case management team here,” observes Dr. Redd. “We’ve developed care plans in conjunction with Access Carroll and local pain management clinics so that patients get a consistent message. That makes it a safer system. As we trend away from opioids, a multidisciplinary approach is helping.”

She adds, “When I have concerns about addiction, it

can be uncomfortable talking to patients about them, but the conversation is important. I say, for example, ‘This medication has lots of harmful side effects. You’ve had three prescriptions already.’ People appreciate knowing that you’re coming from a caring place, and I’ve been received better than I expected. It’s refreshing when someone comes in with pain and doesn’t want opioids because they’ve previously been addicted.”

Dr. Redd and her colleagues have found the Prescription Drug Monitoring Program (PDMP) helpful in determining when patients have gone to multiple institutions. “We can log in to see the number and type of prescriptions, which can influence what I prescribe. While it’s onerous to log in and search in yet another EMR system, with the increasing number of institutions and data, it’s becoming more useful.”

Dr. Redd concludes, “Studies have shown that NSAID’s are as effective as opioids in many cases, and we’ve created fliers educating patients about this. We also use Naloxone frequently, and created a flier for


patients to call the outreach program in Carroll where they can get Naloxone kits. Having these kits readily available to reverse an overdose is life-saving.”

ADDRESSING PAIN WITHOUT OPIOIDS

Ayana Cannon McIntosh, MD, an interventional pain medicine specialist at Global Pain Management, LLC, in Pasadena, Md., notes, “While it is fortunate that assessing a patient’s pain is now recognized as paramount, providers in some settings feel pressured to prescribe opioids for fear of a dissatisfied patient. Patient satisfaction surveys are frequently used to improve the quality of care offered, but also have the potential to drive a physician to practice in a manner that leaves only the patient feeling pleased with the care provided. We need to have more open and honest discussions with patients regarding the risk-benefit ratio of chronic opioid use. Let’s emphasize addressing the source of their pain and treating it with a broad range of therapies whenever possible.”

ADVICE FOR PRIMARY CARE PHYSICIANS

Dr. McIntosh advises primary care physicians to refer patients early should they not respond to

anti-inflammatory medication or a short course of a low-dose opioid. If pain becomes chronic (lasting more than three months), and is not improving, a pain management specialist may be able to offer more comprehensive care.

She welcomes and encourages communication with referring providers. “Treating pain is a team approach, often involving a primary care doctor, a pain management specialist, a neurologist, a surgeon, and/or rheumatologist. It’s comforting for a patient to know that many are working together to improve their quality of life.”

EVALUATING PAIN

To properly evaluate a patient with pain, Dr. McIntosh:n Actively listens to the patient’s description of their painn Completes a thorough history and physical examinationn Orders imaging or additional testing when appropriate

She promotes a multidisciplinary approach to managing her patients’ pain, focusing away from prescribing only opioid medication, and almost always recommending non-narcotic therapies. Medication management may also include anti-inflammatory agents, muscle relaxants, and neuropathic pain agents.

“It is important to listen to the patient describe their pain and medical history in order to select the appropriate medication,” Dr. McIntosh says. “Neuropathic pain medications such as Gabapentin and Lyrica may be used to treat pain that is sharp and shooting, while an anti-inflammatory may lessen pain that is described as sore or aching.”

In addition to managing a patient’s pain medications, many physicians use interventional therapies. She notes, “We are able to place medication around nerves or into joint spaces using advanced radiographic techniques. While these procedures can take just several minutes to perform, the relief may last for weeks, months, or even longer.”

Like many pain management physicians, Dr. McIntosh first trained as an anesthesiologist. She recalls managing pain for patients while they were anesthetized and also post-operatively. “My training taught me that no two patients are alike, and treating

We have to take responsibility as physicians and prescribers to do everything we can to discourage patients from diverting, abusing or misusing these pills.— AYANNA CANNON, MD

Co-Prescribing to Reduce Overdoses ActAt the national level, Congressman John Sarbanes (D-Md.) introduced The Co-Prescribing to Reduce Overdoses Act (HR 3680) to establish programs that prescribe overdose reversal drugs to patients who are at an elevated risk of opioid addiction and overdose.

The act encourages and trains healthcare providers to prescribe overdose reversal drugs, such as Naloxone, when they prescribe common opioids, in an effort to reduce deaths from opioid overdose. As of publication date, the bill had passed the House.


their pain demands this understanding,” she says.

In addition to physical ailments, depression, anxiety and psychosocial factors may heighten a pain response or lower its threshold. “Pain psychiatry is often a recommended therapy, along with medications, physical therapy, acupuncture, and interventional treatments. Living with chronic pain can magnify a host of emotions that a patient may not be able to manage alone.”

REDUCING DIVERSION

To reduce the likelihood that patients will misuse opioids when prescribed, Dr. McIntosh has a few suggestions. “During their initial consultation, we discuss their pathology in detail, as well as available

treatment options. We discuss opioids as a part of a larger plan, and it is important to me that they understand that these medications are not without risk.” Her patients are asked to sign an agreement that outlines her expectations while opioid medications are being prescribed. Her patients understand that violating the agreement may make them a poor candidate for certain medication types.

Dr. McIntosh concludes, “Opioid medication has great therapeutic benefit for the right patient, but we have to take responsibility as physicians and prescribers to do everything that we can to discourage patients from diverting, abusing or misusing these pills. In-office testing and frequent reassessment of a patient’s progress helps to ensure compliance.” CP

Vanessa Redd, MD, an emergency medicine physician with Emergency Medicine Associates at Carroll Hospital in Westminster, Md.

Ayana Cannon McIntosh, MD, an interventional pain medicine physician at Global Pain Management, LLC, in Pasadena, Md.


HOW TO

designFOR CHANGING MEDICAL PRACTICE ENVIRONMENTS

HEALTHCARE DES IGN


hether you work for a large system or you run a private practice, understanding the design of your environment, and recognizing opportunities in the evolving design logic of clinic space planning, will allow you to improve efficiencies, your bottom line and your care environment. Our benchmarking data shows that 90% of available resources are dedicated to providing and supporting processes related to patient care. Considering that medical errors, patient safety and experience are also directly related to these processes, optimizing even minor efficiencies can greatly improve the bottom line and also support the reputation of the provider brand. Similar benefits can be achieved by understanding the core principles of environmental design and correcting deficiencies through thoughtful design.

PLANNING, BENCHMARKING, DEMOGRAPHICS ARE KEY TO SUCCESS

Careful planning can mitigate design challenges and steer the project in the right direction. The first step is to consider recent developments in industry trends and understand how you fit into the overall healthcare system stream. Measuring a few data sets, patient throughput and staff efficiency, for example, will allow you to benchmark your practice against similar provider models and identify potential efficiencies. Predictive analytics can help align your operations with similar values of the comprehensive care system in which you operate, and more importantly allow you to position yourself for where it is heading.

Ambulatory settings, including multidisciplinary practices with integrated diagnostics and outpatient surgery centers, are growing both on and off hospital campuses. On-campus sites that were traditionally institution-based are expanding their outpatient services,

BY BRIAN MARTIN

FOR CHANGING MEDICAL PRACTICE ENVIRONMENTS

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Use interior finish patterns and color to help patients navigate your facility

The design

of your practice

influences

patient

and staff

satisfaction.


A dynamic and flexible model can

accommodate multiple physician team

strategies within the same space, allowing

physicians to tailor their care delivery to fit the

strengths of their teams and preferred method

of practice.

combining them with physician groups in settings that entail less expensive construction. Growth strategies also have a lot to do with population density and patient

convenience. Networks serving denser urban population centers are opening local neighborhood clinics to improve accessibility, while community and critical access care systems that serve rural areas are adding to their primary location so patients do not have to travel to multiple places to get comprehensive services.

CENTRALIZED SUPPORT SERVICES CREATE EFFICIENCIES

Teams that share support resources are moving to centralized:nReceptionnAppointmentsnBilling servicesDepending on the services you offer, you can also recognize efficiencies by sharing

other administrative staff who perform similar tasks. Additional revenue can be captured

Amenities can enhance waiting areas and provide more discreet family-oriented spaces


by including lab and imaging diagnostics on site and adding selective ambulatory components, such as outpatient surgical procedures that require general anesthesia. Aside from reduced redundancy and lower labor costs, the co-location of multiple complementary practices enhances patient convenience by creating a one-stop shop for the majority of their services in an increasingly consumer-driven healthcare industry.

These models also provide quality of care benefits. Team-based multidisciplinary clinic layouts with centralized staff zones have been proven to improve communication among providers, staff and patients. A dynamic and flexible model can accommodate multiple physician team strategies within the same space, allowing physicians to tailor their care delivery to fit the strengths of their teams and preferred method of practice. These models look at key performance factors and metrics to test design options and ensure improved operational performance when the building is occupied.

HOW TO MAXIMIZE STAFF COMMUNICATION AND PATIENT EXPERIENCE

Clinical practice design should maximize staff communication and knowledge transfer, as well as patient navigation. For example, placing the centralized staff adjacent to physician team stations improves communication between the care team and support staff, which can reduce patient wait times. This strategy has the added benefit of improving communication among team members, and promotes best practices within the facility, as well as improved social environment, which has been a key indicator of improved staff attendance.

Placing the centralized staff adjacent to physician team stations improves communication between the care team and support staff, which can reduce patient wait times.

Locate staff areas in sites visible to patients to promote access


Placing the care team work zone closer to patient treatment areas can mitigate medical errors and minimize travel distances between exam and treatment areas, allowing physicians and staff to spend more time on patient needs. Similarly, decentralized equipment and supply localization allow staff to quickly obtain frequently used items without leaving the patient for an extended period of time.

Staff should also be accessible to patients; visibility improves patient navigation and way finding. Patient comfort is further enhanced by subdividing larger waiting areas into smaller zones with more discreet seating arrangements, allowing patients to bring family members for support if needed, or small children. Modest amenities to accommodate them can improve their perception of their overall care experience.

The environment of care is evolving rapidly. Planning for future adaptability can help ensure your patients and staff get the most out of your facility, allow team members to perform at their highest level and save money. CP

Brian Martin, AIA, LEED AP, EDAC is a senior designer in the healthcare studio at SmithGroupJJR. He can be reached at [email protected].

www.IMMH2016.com

Placing the care team work

zone closer to patient treatment areas can

mitigate medical errors.


he Center for Medicare and Medicaid Innovation (CMMI) is testing various groundbreaking payment and service delivery

models, with the goal of improved care and smarter spending that also provides innovative new reimbursement options for primary care physicians.

Supporting the Future of Primary CareIn April 2016, CMMI announced the

launch of Comprehensive Primary Care Plus (CPC+), a new model that will be the largest test of a primary care medical home model in the country’s history. It follows the Comprehensive Primary Care initiative (CPC), which began in 2012 and runs through the end of this year, with nearly 500 participating practices. CPC+ is a five-year multi-payer model in up to 20 markets around the country that will include up to 5,000 primary care practices.

In May, CMMI announced they would allow up to 1,500 practices to participate in both CPC+ and a Medicare Shared Saving Program ACO.

CPC+ Market SelectionTo determine which markets will

participate, CMMI first asked payers to submit applications through the first week in June. CMMI is selecting up to 20 markets based on these applications, and then providers in those markets can apply beginning in July.

The Center is looking for a critical mass of payers in certain markets. Partnering payers sign a memorandum of understanding with CMS and agree to align with CMS on payment, quality measurement and data feedback to practices.

Three Models of InnovationOverall, CMMI is testing three key

alternative payment models – accountable care organizations (ACOs), bundled

payments, and advanced primary care medical homes. Within each of those broad categories, the Center seeks to offer a model that can meet providers at different stages.

The CPC+ model is for primary care providers that are on average smaller than most of the CMS ACOs. A core feature of the model is that providers receive a care management fee, selecting one of two tracks. Track One, on average, has a care management fee of $15 per month per Medicare beneficiary. Track Two offers $28 per month per beneficiary, on average.

Providers can also receive a performance bonus linked to utilization and quality. The Center’s goal is to make primary care more financially appealing while giving providers more resources to practice in the way they want to practice. Under the model, physicians will work in teams with mid-level providers and other staff, such as community health workers, nurses, care managers and care coordinators.

Challenges in Implementing ReformAs CMMI seeks to tackle some of

the most difficult issues in healthcare policy, it faces challenges in designing models, creating the right incentives and ensuring that every CMMI model has a business case for providers as well as the government, with quality care for its beneficiaries.

The Evolution of ACOs As of 2016, there are over 470 CMS

ACOs. In January 2015, Health and Human Services Secretary Sylvia Mathews Burwell

set goals for moving 30% of Medicare recipients into alternative payment models by the end of 2016, and 50% by the end of 2018. CMS reached the 30% goal 11 months ahead of schedule.

Some 64 ACOS are in two-sided risk plans. While a few ACOs exited the initial Pioneer ACO program, the vast majority of those entered a newer ACO program. These Pioneer ACOs delivered $384 million in two-year cost savings, and many bundled payment initiatives are showing promising early results.

All ACO models contain a learning system where the participants form affinity groups and share best practices in transforming away from fee for service to fee for value – whether it be finding ways of risk-stratifying a patient panel, or examining different ways to design post-acute pathways.

Advice for Shifting from Fee-for-Service to Population Health

Practices of all sizes can make the shift to population health. The average practice size in the CPC initiative is four providers, with solo and two-physician practices also participating. The Center’s goal is to provide enough support and resources to allow these practices to make that transition to the next step.

CMMI advises physicians to review its current primary care options, choose a payment model that best fits their practices, and develop the core skills necessary to succeed in that model. CP

The goal is to make primary care more financially appealing while giving providers more resources to practice in the way that they want to practice.

POLICY

Bringing Innovation to Government Reimbursement

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With all the flavor of the Chesapeake Bay Blue Crab —

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