selection. Unfortunately, it's actually not about patient selection. I'm gonna explain a little bit more as I go through. First off, my disclaimers is that I am an owner in two surgery centers. I'm the director of one, but I don't do outpatient joint replacement. I don't do knee or hip arthroplasty. It's given me kind of an interesting bird's-eye perspective on the whole process because I've been instrumental in setting up our own pathway, as well as seeing where we were successful and where we failed. So why do you want to do this? We get, we like data, we like transparency. I would tell you that this is kind of general numbers, but if you look at those, total joint replacement surgeon, that's a relatively efficient joint replacement surgeon versus a relatively busy sports surgeon, a hand surgeon. You see what they're making per minute in the operating room on a facility fee reimbursement standpoint. That takes into account implant costs, how long it takes you to do a surgery, staffing costs, anesthesia costs, everything. So you see the driver and where this is going. The reason we're moving into an ASC setting, this is pretty obvious to most of us now that are living in the outpatient world, decreased infection rates, increased satisfaction, decreased cost, and actually decreased opioid consumption too. And a lot of that's probably because of a focus on the process that goes into this. So a lot of benefits. So outside of just cost, there's a lot that's going into this. And we see this replayed over and over again in the literature. So patient selection. The first and actually most important thing, if you're starting to get into a busier center with outpatient joint replacement, is not patient selection, but surgeon selection. I can give you lots of examples of surgeons that we have that don't do a real great job with patients that are absolutely primed to be ready to go. And I can give you lots of examples of surgeons that are taking patients that should not be going to an ASC setting per guidelines or per accepted recommendations that do a fantastic job with them. And a lot of that has to do with that lead surgeon as we move into outpatient joint replacement. That surgeon needs to be efficient, they need to be a good communicator, and they need to be willing to get involved. If you don't have someone that's willing to do these three things, I can almost guarantee you that the move to an outpatient joint replacement program is going to fail. This can't be done by sports surgeons, this can't be done by surgery center directors that are then convincing joint replacement surgeons to go. The second thing is education. So we've also learned that if patients aren't appropriately educated through one common pathway, so not each practice educates and hands out a booklet, but if patients aren't educated through one common pathway the same way every single time, it affects how many people feel comfortable going to a surgery center and how many people do well with going to a surgery center. So it's really important that you focus on education, but more important that you focus on the process of providing that education. So once you start to have these two things down, now we start to get into patient selection. Okay, you have a surgeon that's good at what they do, they communicate, they're a good surgeon, and you have an appropriate educational process that takes a patient through the whole pathway. There's not really a lot of great risk assessments out there looking at an ASC risk assessment. There's lots for bundled payments in a hospital-based environment. The Ohio group, who probably has done as many outpatient joint replacements as anybody in the country, has a risk assessment score that really takes nine health categories into play, and if you get a score of less than 79 there's a pretty good positive predictive value that you're going to do well in an ASC setting. Most of us that are doing this aren't necessarily using as defined of a system and are kind of figuring this out as we go. I can tell you that our experience through all of this, and I'm going to reiterate this again as we go through, is that the first and most important thing is not whether or not a patient is optimized from BMI, smoking, diabetes, but whether or not they're willing to go and they're interested in going to a surgery center. COVID has, one of the silver linings in COVID for an ASC outpatient orthopedic group is that now everybody wants to go to an outpatient setting. The idea that I want to stay, I feel more comfortable staying in a hospital overnight, has certainly changed over the last year and a half. So there's been a dramatic exponential increase in the number of willing patients that are going. If you're trying to force a patient kicking and screaming to an ASC setting, they're not going to do well. Readmission rates are higher as well as satisfaction is lower. One thing that we found that's really an integral part that's even more important than those health related factors is whether or not they have a support person at home. You can build in some of that around with home health and other things, but really it comes down to is do they have an involved partner, family member, friend that's going to be a support person for them at home that's going to go through this educational process with them. If you have that person, a lot of the health indicators, and I'll show you in a minute or two what ours are, aren't necessarily going to matter. That person carries a lot of weight. And then finally we get into the general health requirements. Again, not the most important thing when looking at outpatient joint replacement in an ASC setting. These were our initial exclusion criteria, which I think are probably pretty common across the country. BMIs greater exclusion criteria. So BMIs over 35, age over 60, a host of different medical issues. We really wanted to tailor down patients that would do well in an ASC setting. We've been doing outpatient joint replacement for probably the last six or seven years now, and as we started to go through, we started to question this a little bit more. I would tell you that our current exclusion criteria will do patients with a BMI under 40, and will even do patients with a BMI under 45 with appropriate anesthesia review. Chronic anticoagulation therapy doesn't do well in an ASC setting. Pre-existing implants were not to the point, although we may be getting there for revision surgery. Lack of home support. So you see COPD, cardiac disease, all these other things dropped off the list, but all of a sudden lack of home support came on the list, and that's through experience. Hemoglobin, A1c greater than 7, would also be an exclusionary criteria. Potentially more relevant in this surgeon population is outpatient shoulder replacement, which we're also doing. These patients we apply the same exclusionary criteria to, although probably a little bit more lenient for specific cases. We find that not ambulating on that shoulder allows them to be a bit more functional, a bit quicker. So we've done with these current exclusionary criteria over a thousand joint replacements, and we're still at half the Medicare infection rate and half the Medicare readmission rates. We're building more surgery centers in states with certificates of needs, and this is actually very, very important data that we use for those applications, and we're going at it alone with no partners currently. So some lessons that we've learned as we go through. So surgeon skill set is very important. There are surgeons that are not going to migrate well to an ASC setting, and there's unfortunately not a lot that you can do around that. There are surgeons that are going to take and run with it. Our busy joint replacement surgeons, with the new outpatient joint replacement surgery center coming, expect that within the next two to three years, 80% of all of their patients, including Medicare, will be in an ASC setting. Education is really paramount, defining a process for that education, that single source of education. Patient expectations, starting that from start to finish, so that the patient is seeing the same set of expectations applied to them all the way through. Responsiveness is really important too. We've seen lots of patients that have anxiety with getting a joint replacement in an outpatient setting. They go home and they say, is this normal? Is that normal? Am I having more pain than I should? If there's not a team member that's responsive and a high-level understanding of what's going on, those patients will default to going to the emergency room because they're concerned about their situation, that they're not in a hospital. Having that support person, you've heard this over and over again, is really important. But I thank you for your time, and hopefully we'll have some good discussion around this, as they're always fun topics.

outpatient joint replacement programs

ambulatory surgery centers

surgeon selection

education

patient selection