26 September 2016

How to Manage the Burdens of Change on Physicians and Health Care Practitioners

The high cost of U.S. health care continues to grow, thanks to a combination of factors including inefficient care delivery, operational processes and expansion of health care coverage to vulnerable populations. The need to curb these spiraling costs is clear while improving the value of the overall spend. But the shift to value-based care and related health care reform initiatives by both the government and the private sector are burdening health care providers with unreasonably complex, time-consuming and costly record keeping and reporting requirements, thereby encouraging physicians and other practictioners in private or small practices to either join large provider organizations, such as hospitals and physician services providers, or give up practicing medicine altogether. 

Sheridan’s Chief Quality Officer Dr. Gerald Maccioli recently spoke at the 2016 Health:Further Summit about the overwhelming burdens on providers created by current and planned changes to the U.S. health care landscape and offered strategies for managing those burdens.

The Current State of U.S. Health Care

 

VUCA: “The New Normal” Working Environment for Health Care Providers

Dr. Maccioli began with an overview of the current state of U.S. health care. He used the term VUCA – a concept introduced by the U.S Army War College to describe the volatile, uncertain, complex and ambiguous world environment following the end of the Cold War – to characterize “the new normal” for physicians and other health care providers following the enactment of the Affordable Care Act and now MACRA.

U.S. Health Care Quality

A frequently cited study by the Commonwealth Fund International Working Group on Quality Indicators ranked U.S. health care eleventh globally. But Dr. Maccioli pointed to several other reputable studies and analyses that challenge those findings. The CONCORD study of cancer survival in five continents found that the U.S. ranked first for breast, prostate, and colon cancer survival. The American Enterprise Institute’s report on “The Business of Health” found that when fatal injuries (which are often unrelated to health) are excluded, the U.S. ranking moves up to first place. And researchers at the University of Pennsylvania found that low life expectancy in U.S. is “not likely to be a result of a poorly functioning health care system.” Those metrics indicate that U.S. health care is, in fact, the best in the world.

Health Care Spending Is Outpacing GDP Growth

Since 2009, health care costs in this country have represented more than 17 percent of the gross domestic product (GDP). And despite measures designed to curb those costs, such as the Affordable Care Act, those high costs continue to grow. In 2013, the U.S. spent $2.9 trillion on health care, or $9,225 per capita. And that spend is projected to increase at a rate of 5.7 percent annually – 1.1 percent faster than GDP growth – through 2023, when health care spending will likely reach $5.2 trillion, 19.3 percent of the projected GDP. 

So the primary focus of health care reform should be on increasing efficiency and lowering the cost of care delivery, thereby improving the “value” to both the individual patient and society as a whole.

Three Stakeholders = Three Agendas

Patients are demanding consumer-driven, high-deductible plans with greater pricing transparency. 

Providers are retooling operations to infuse more focus on care management, cost reduction, data utilization, prevention and overall wellness.

Commercial payers are consolidating, becoming more powerful, and both commercial payers and CMS are shifting risk to providers (both downside and upside risk, based on outcomes). Payers are also increasing the number of value-based programs, such as bundled payments, pay-for-performance and shared savings plans. 

The metrics for rating physicians’ quality performance were decided on by federal health officials and insurers. The American Medical Association, various medical groups, patient advocacy organizations and the insurance industry hastily applauded the agreement, glad to finally get broad consensus between CMS and commercial insurers on how physicians would be measured on quality. But that was before more detailed metrics were revealed in the proposed MACRA implementation rules.

Corporate Leaders Adding to Market Pressure

As we discussed in a previous post, 20 major U.S.-based employers with four million covered lives banded together in February 2016 to form the Health Transformation Alliance (HTA). The HTA’s stated goal is “to improve the way corporations provide health care benefits in an effort to create better health care outcomes for their employees. By coming together to share expertise, the companies seek to make the current multilayered supply chain more efficient.” 

These large corporations are pooling their employee health care data to analyze spending and outcomes to identify the best treatment options/providers. HTA is expected to design plans with high-performing providers to deliver high-value care to employees and their families. The group also may eventually use its members’ combined purchasing power to drive down the cost of prescription drugs. 

Complex and Inconsistent Quality Reporting Requirements Have Made Reporting Expensive and Time-Consuming 

Dr. Maccioli highlighted the lack of standardization or alignment in quality reporting requirements. In addition to a panoply of federal requirements in the current CMS quality reporting programs, there are also more than 500 state quality measures in total. There is only 20 percent crossover of those measures among states and medical specialties. In addition, individual insurers and even health organizations often require their own metrics. The cumulative burden of data collection to comply with externally imposed requirements creates an almost unbearable administrative burden for doctors.

Complying with federal and state government and commercial payers’ quality reporting requirements costs U.S. physician practices more than $15.4 billion a year, according to a recent article in Health Affairs that estimates a cost of $40,000 per physician practice annually. 

On average, providers in these practices spend 7.6 hours each week on quality reporting – time that otherwise could have been spent delivering patient care. In addition, staff in these practices spend an average of 15.1 hours per week on documentation and reporting activities. 

Challenges related to the current state of EHR technology, such as poor usability, time-consuming data entry, interference with face-to-face patient care, inability to exchange health information because of interoperability issues, have significantly lowered doctors’ professional satisfaction in recent years. And the cost, complexity and time burdens of complying with changing quality reporting requirements are becoming so high that many doctors can no longer afford to remain in private practice or smaller physician practices.

Heavy Burden on Doctors Leads to Physician Burnout

Dr. Maccioli pointed out that these overwhelming burdens on physicians are major contributors to this country’s physician burnout epidemic. “They are taking the joy out of medicine” and creating debilitating stress levels, he explained. “Physicians are scared. There is so much pressure on them that modern medicine doesn’t prepare them for.” More and more doctors are taking early retirement or even changing professions, exacerbating the increasing physician shortage crisis.  

Seismic Shifts in Health Care Will Multiply the Burdens on Health Care Providers

 

After reviewing the current state of U.S. health care, Dr. Maccioli addressed the fundamental shifts that are taking place and further increasing the burdens of change on health care providers over the next 8-10 years.

Medicare’s Shift to Value-Based Care

The goal of the CMS is to have 50 percent of all Medicare payments and 90 percent of Medicare fee-for-service payments tied to quality or value by the end of 2018. It is developing and testing new payment models that could put hospital-based physicians at a high risk of commoditization. Yet the stated goals of these programs are encouraging greater integration, coordination among providers and attention to population health, and accelerating the availability of EHR information and interoperability. 

The Medicare.gov website allows consumers to compare data on costs and quality.

Hospital Value-Based Purchasing

CMS’s Hospital Value-Based Purchasing (VBP) Program, which rewards acute-care hospitals for the quality of care they provide to Medicare beneficiaries, is shifting its measurement focus from process measures to outcomes. 

The Macro-Level Market Shift

The revenue mix for providers is shifting rapidly from fee-for-service to value-based reimbursement. 

Dr. Maccioli emphasized that in order to meet value-based goals, both physicians and hospitals will need to reduce utilization among their patient populations, which could potentially reduce their procedure volume and, thus, their revenue.

MACRA Payment Tracks: MIPS and APMs

Dr. Maccioli laid out the two payment tracks for physicians under MACRA – the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs) – and presented a quick summary comparison. As of this spring and the proposed implementation rules, these programs are now collectively known as “QPP” (Quality Payment Programs).

Physicians’ revenue will be at risk in one way or another in both payment tracks. However, Dr. Maccioli pointed out, MIPS can serially increase physicians’ compensation without requiring them to assume actuarial risk for care. Because CMS wants to shift more and more risk to providers, it is pushing the use of APMs, including bundled payments, medical homes, and prevention and team-based APMs, by giving participation bonuses to participants in qualified APMs and offering additional incentive bonuses to participants in the most advanced APMs – read those that require providers to assume the most actuarial risk for care. 

Dr. Maccioli also noted that APMs could well become a graveyard for many hospital-based specialties. 

What’s Certain to Change

While there is always the possibility of changes to the proposed MACRA rules between now and the release of the final rule (expected November 1 or thereabouts), the fundamental changes to the CMS payment structure under MACRA are certain. 

  • Providers will need to be on the fee-for-service (FFS) MIPS track or the APM track, and the basic payment framework for each won’t change.
  • Providers in the MIPS track will receive PFS (physician fee schedule) updates, as in the past, plus a new MIPS FFS adjustment (up or down) based on a composite performance score in four weighted performance categories (initially quality, resource use, clinical practice improvement activities and meaningful use of certified EHR technology). During the first six years (2019-2025), providers with composite performance scores in the top 24 percent will also receive an additional positive adjustment factor (capped at 10 percent per eligible provider).
  • For those in the APM track, most physicians and practitioners who participate in APMs will receive favorable scoring under the MIPS clinical practice improvement activities performance category as well as APM-specific rewards. A smaller number of providers participating in the “most advanced”/highest-risk APMs who are determined by CMS to be Qualifying APM Participants (QPs) will receive the most favorable treatment. QPs will not be subject to MIPS and will receive guaranteed five percent lump sum bonus payments for years 2019-2024, and then a higher fee schedule update in 2026 and future years.
  • Annual updates to the PFS will be made starting in 2026 – 0.25 percent for MIPS and 0.75 percent for APMs.
  • The current Medicare quality and value programs, PQRS (Physician Quality Reporting Program), VM (Value-based Payment Modifier) and Medicare EHR Incentive Program (AKA “meaningful use”) will sunset at the end of 2018.

What May Change

CMS has received more than 4000 comment letters since the proposed MACRA implementation rules were put out this spring. As a result of these overwhelmingly negative comments, a September 8, 2016 statement by CMS Acting Administrator Andy Slavitt proposed a possible implementation compromise with potential changes to the MACRA implementation schedule. 

The basics of the proposed compromise pathways are as follows (the options will be fully elucidated in the final rule):

  • Option one: Test the program
    According to Slavitt, as long as you submit some data to the MACRA Quality Payment Program (QPP), including data from after Jan. 1, 2017, you will avoid a negative payment adjustment. This option is intended to ensure that the system is working and that physicians will be prepared for broader participation in the coming years as they learn more.

  • ​Option two: Partial-year reporting
    Physicians can choose to report Quality Payment Program information for a reduced number of days. You could choose a first performance period that begins well after Jan. 1 and your practice could still qualify for an incentive payment.

  • Option three: Full-year reporting
    If your practice is ready to get started on Jan. 1, you can choose to report Quality Payment Program information for the full calendar year. Your first performance period would begin on Jan. 1, and if you submit information for the entire year your practice could qualify for a modest positive payment.

  • Advanced Alternative Payment Model (APM) option
    This option is still available and qualified participants in advanced APMs will be eligible for five percent incentive payments in 2019.

Choosing any of these four options guarantees that you will not receive a negative payment adjustment.

However, Dr. Maccioli emphasized that the actual implementation schedule won’t be known until the Final Implementation Rule is revealed during the first week of November. He said that even if MACRA is delayed, “We need to plan as if MACRA reporting will commence Jan. 1, 2017!“ – a view also shared by The Advisory Board

Quality Reporting Will Become Even More Onerous and Costly

H.R. 2 Medicare Access and CHIP Reauthorization Act, AKA MACRA, requires all providers to prepare for both Merit-Based Incentive Payment System (MIPS) and Alternative Payment Methodology (APM). This requirement means that although MACRA’s new payment structure changes won’t go into effect until 2019, providers should assume that they must move claims-based quality reporting to registry reporting via a qualified clinical data registry (QCDR) by Jan. 1, 2017 – just three months from now – or face significant penalties from CMS.

The need for eligible professionals (EPs) and PQRS group practices to contract with a QCDR to avoid the 2018 PQRS negative payment adjustment will create a significant incremental expense for those providers. And having to prepare and submit quality data to the QCDR in a complex and rigid format will add yet another layer of complexity to quality reporting. 

And between 2017 and 2019, providers will need to collect and submit two different sets of quality data simultaneously – claims-based data and QCDR/registry-based data.

Which Road Should Providers Take?

Beginning in 2019, physicians will be paid according to either a merit-based incentive payment system (MIPS) or through an alternative payment model (APMs). Practices must choose one of those two paths for reimbursement moving forward. Dr. Maccioli advised that even though physicians will be allowed to switch between models from one year to the next, now is the time to select their initial approach and put the appropriate infrastructure into place.

Which is the best choice? It depends. MIPS is closer to the previous fee-for-service model and carries much less risk than participating in APMs. On the other hand, APMs offers the highest maximum reimbursement rate – a guaranteed five percent annual payment increase from CMS over the first six years of the program, within the construct of an ACO… but you have to take whatever the payers define as an APM, which could well change during the course of any year.

Dr. Maccioli said in his opinion, “we have to prepare for MIPS and avoid APMs.”

Preparing for MACRA/QPP’s Impact

 

Famed British philosopher and logician Bertrand Russell (1872-1970) said, “What men want is not knowledge, but certainty.” Dr. Maccioli promoted the “VUCA Prime” concept introduced by Bob Johansen, Distinguished Fellow at the Institute for the Future, to help organizations reduce the instability associated with the VUCA environment. Johansen asserts that the most effective leaders in the VUCA world counteract volatility, uncertainty, complexity and ambiguity with vision, understanding, clarity and agility. 

Dr. Maccioli outlined the opportunity for entrepreneurs, investors and IT professionals, stressing that provider success in the VUCA world will be contingent on three things:

  • Interoperability - seamless administrative and EHR data integration.
  • Efficient Documentation Tools that reduce the burden on physicians and practitioners and increase their time with patients.
  • Analytic Prowess with Learning Systems – a virtuous cycle of improved patient care and learning.

He reminded attendees that all their “customers” are also in the VUCA world, and that because health care providers are in a high emotion/high cost arena, they need to ask themselves the following questions, based on the October 2015 Harvard Business Review article, “When The Customer Is Stressed”:

  • What about our service is most likely to trigger intense emotions?
  • If customers could magically make one improvement to our service, what would it be?
  • What can we do to make first impressions of our exceptional service?
  • What are the “never phrases” we need to banish?
  • What skills and knowledge are critical to upholding our core purpose?
  • How can we learn from each other to perform at peak levels?

Dr. Maccioli also presented his biases, saying he believes health care administrators and physician leaders should frame any enterprise change or decision with the quadruple aim in mind, i.e., Improving the work life of health care professionals, enhancing the patient experience, improving population health, and reducing costs. He believes that even the best-designed solutions to modern health care issues won’t work “if we don’t improve the work life of physicians.”

Dr. Maccioli also said he firmly adheres to a “just culture” approach – creating an atmosphere of trust, accountability, learning and ongoing improvement. (This is in sync with the Japanese Kaizen philosophy and continuous lean process improvement approach used by Sheridan, which has a dedicated office of Kaizen event facilitators.) He emphasized two key concepts of the “just culture” approach:

  • Humans inevitably make mistakes, and human error and adverse events should be considered outcomes to be measured and monitored with the goal reducing errors and improving system design.
  • Accountability is shared. While everyone is accountable for the quality of their choices, healthcare organizations are accountable for the systems they have designed. Caregivers should be held blameless when errors happened that were not prevented by a systems or processes.

Learn more about what Sheridan is doing now to help physicians reduce the increased quality reporting burdens on physicians under MACRA beginning in January.

19 September 2016

How Physicians, Hospitals and Health Systems Are Dealing With the U.S. Drug Shortage Crisis

The ongoing drug shortage crisis in the U.S. is sending prices for some medications skyrocketing, forcing hospitals and physicians to scramble for alternatives and threatening the safety of patients. These shortages have been causing major problems nationwide for several years, but the causes are complex and not easily fixed, and doctors, hospitals, health systems and acute-care facilities continue to struggle to find effective workarounds.

The number of drugs in short supply in this country has more than tripled in the past decade. Since 2012 when the Food and Drug Administration Safety and Innovation Act (FDASIA) took effect, that number has decreased overall. Yet shortages of drugs commonly used for unscheduled acute care in emergency rooms, intensive care units and other health care facilities have continued to increase in both number and length, with an approximately eight-month median duration. 

Multiple Causes Make Drug Shortages Hard to Fix or Prevent

Most U.S. drug shortages are caused by one or more of the following:

  • Manufacturing / production issues:
    • ​Quality control problems
    • Lack of availability of raw materials
    • Shipping delays
    • Production capacities that either cannot or have not yet ramped up to meet increases in demand
  • Economic issues / business decisions: 
    • ​Market share erosion that causes brand-name drug manufacturers to discontinue production when generic versions enter the market
    • Mergers or acquisitions involving pharmaceutical companies that manufacture the same medication, which typically results in one of those drugs being discontinued for business reasons
    • Discontinuation of older medications in favor of newer, more profitable ones
  • Regulatory issues:
    • Slow FDA approvals for new drugs
    • Pricing constraints tied to federal reimbursements
    • FDA warnings and bans that result in the temporary suspension of production at particular plants or permanent discontinuations of certain products, including commonly used injectable opioids such as morphine and oxycodone and injectable benzodiazepines such as diazepam, midazolam and lorazepam

The Sterile Injectable Drugs Shortage: A Perfect Storm

Sometimes more than one of these factors contributes to the shortage of a particular drug or type of drug. The persistent shortage of sterile injectables – including essential drugs like sterile saline solution and antibiotics that can be effective against superbugs – is the result of a perfect storm of manufacturing, economic and regulatory issues. 

According to a recent article in Forbes, sterile injectable drugs are more expensive to manufacture and notoriously difficult to produce safely, yet because they are subject to federal Medicare and Medicaid reimbursement policies they often have artificially low selling prices. In addition, the FDA’s increased scrutiny of sterile IV fluid manufacturers after particulate matter was found in some products a few years ago has led to recalls, manufacturing delays, and product discontinuations of some sterile injectables. 

Shortages of injectable antibiotics that have been shown to be effective in treating drug-resistant bacteria present another serious challenge, especially in light of the alarming evolution of superbugs. A recent example is this year’s shortage of amikacin sulfate. Amikacin has been shown to be active against certain gram-positive and gram-negative bacteria including Staphylococcus series, Klebsiella series and E. coli, both in vitro and in clinical infections. It also may be the aminoglycoside of choice for serious nosocomial gram-negative infections in areas where resistance to gentamicin or tobramycin is present. Teva Pharmaceuticals is one of the few companies that manufacture amikacin. FDA inspectors who visited Teva’s sterile injectables plant in Hungary in January cited issues with the “current good manufacturing practices” (CGMPs), the regulations for pharmaceutical manufacturing processes and facilities that the FDA enforces. Teva responded by suspending production of all but two of the roughly 200 drugs that were being made there “as a precaution” while it continues to work to resolve those issues to the FDA’s satisfaction. Only amikacin and bleomycin, a cancer treatment drug, continued to be produced at the facility. The FDA subsequently issued an import alert banning all the products made at that plant from the U.S., with the exception of amikacin and bleomycin. But on August 2, Teva announced a voluntary recall of seven lots of amikacin sulfate, citing concerns about the potential presence of glass particulate matter, and as of August 31 the ASHP current drug shortages page includes both amikacin and bleomycin. 

Other manufacturers of sterile injectables have also been forced to halt production at plants outside the U.S. while they address FDA warnings and concerns. Over the past several years, FDA warnings for Hospira plants in Europe, North America, Asia and Australia have caused production stoppages. Pfizer, which acquired Hospira last year, announced a temporary production halt at a plant in India last month after a team of inspectors from four of the world’s leading regulatory agencies, including the FDA, found a number of lapses in good manufacturing practices. 

Price Gouging Exacerbates the Problem

Shortages and discontinuations of drugs that have unique applications or are produced by only one manufacturer have even more severe repercussions. And manufacturer price gouging for these medications is becoming a huge problem. The FDA has been slow to approve new medications that could provide market competition that would drive down prices as well as create alternative options for health care providers during shortages of either drug. 

Another emerging source of price gouging is the misuse of the Orphan Drug Act (ODA). More and more companies are purchasing the rights to existing drugs and submitting them to the FDA for approval as orphan drugs for a different use, to treat diseases that affect fewer than 200,000 people in the U.S. Under ODA, makers of approved orphan drugs get tax credits for half the cost of clinical development (even though companies that purchase the older drugs didn’t pay for the development costs), seven years of exclusivity, and waived fees. So once the FDA approves the drug as an orphan, the drug makers relaunch them under a different name and charge exorbitant prices. 

This trend has a wider impact than it might appear because many of those “orphan” drugs are frequently used off-label to treat much more common conditions, making this practice even more profitable for drug makers. And repeated attempts to curb misuse of the law by ending drugs’ ODA status and benefits once the drug’s target population or sales exceeded a certain threshold have been blocked.

International Politics Have Led to Shortages of Sedatives, Paralytics, Anesthetics and Other Drugs

Commonly used sedatives, paralytics, anesthetics and other drugs that have been used not only by hospitals for medical purposes but also by U.S. correctional facilities as anesthetics for lethal injections have become limited or discontinued. A global campaign by opponents of the death penalty or lethal injections against makers of drugs used for that purpose brought intense pressure to bear, causing many of the manufacturers to stop producing them or severely restrict their distribution. That has left physicians and hospitals scrambling for alternate sources as well as alternative medications.

Hospira, the only U.S. manufacturer of sodium thiopental (Pentothal), is one example. The company had halted production of the drug in 2009 because of manufacturing issues in a North Carolina plant, and after spending two years trying to bring the closed facility into compliance with the FDA CGMPs, had planned to shift production to a plant in Italy. But Hospira was forced to exit the market permanently in 2011 instead after Italian officials said they would not permit the product to be released out of Italy if it could potentially be used for lethal injections.

Some paralytic agents also are no longer being produced for similar reasons, and those that are in production are extremely expensive. There also has been a shortage of agents used to reverse those paralytics, and the prices of those that are available have gone up dramatically; a drug that used to cost roughly $10 per vial can now cost close to $100. 

The FDA’s Dilemma: Balancing Quality and Supply

The FDA is under tremendous fire from two opposing factions: those who argue that the agency’s more zealous inspections and enforcement actions in recent years have been largely responsible for the drug shortage problem, and those who say that zeal must be maintained to protect this country’s patients by ensuring the safety and efficacy of the U.S. drug supply. The FDA’s efforts to straddle this supply/quality tightrope by making exceptions or finding loopholes in the enforcement of its good manufacturing quality practices have often been met with criticism. 

Faced with the sudden shortage of sodium thiopental in 2011, several U.S. states imported untested sodium thiopental for use in lethal injections from a questionable distributor in the U.K., leading the British government to ban the sale of sodium thiopental from the U.K. And a federal appeals court later prohibited the FDA from letting sodium thiopental from foreign suppliers into the country.

In another example, when the agency issued an indefinite ban on a factory belonging to one of China’s leading exporters of pharmaceuticals products last year, the FDA made a highly controversial decision to allow the banned plant to continue exporting about 15 ingredients for use in finished drugs in the U.S., including widely used chemotherapy ingredients doxorubicin and daunorubicin, to avoid possible shortages of key drugs. 

FDA’s Push to Modernize the Pharmaceutical Manufacturing

The FDA has begun working with drug makers to modernize manufacturing methods. This proactive collaboration with drug makers is a new approach “to help the industry adopt scientifically sound, novel technologies to produce quality medicines that are consistently safe and effective — with an eye toward avoiding drug shortages.” The agency says it is encouraging pharmaceutical industry to develop advanced manufacturing technologies, as other industries have done, in order to “create a more robust drug manufacturing process with fewer interruptions. This will minimize product failures and provide greater assurance that the product will consistently deliver the expected clinical performance.” The FDA has established an Emerging Technology Team (ETT) that is providing guidance to drug companies pursuing new technologies, engaging in a dialogue with them early in the technology development process to help identify and resolve scientific issues for new technologies before a drug application is submitted. The agency says it worked closely with the manufacturer of the first-ever 3D printed pill, for epilepsy drug Spritam (levetiracetam), to make the use of 3D printing technology for this application a reality. The agency recently approved the pill, which it says “can disintegrate more rapidly in a patient’s mouth, greatly aiding those who have trouble swallowing.” 

What Can Physicians, Hospitals and Health Systems Do?

Until long-term solutions to the underlying problems causing ongoing drug shortages are agreed upon and implemented, physicians, hospitals and health systems need to continue to develop strategies to acquire vital medications in short supply and workarounds for those that are unavailable. They can also become active in advocacy efforts to help shape effective solutions. 

Use Group Purchasing Organizations (GPOs)

Many hospitals belong to group purchasing organizations (GPOs) that leverage member organizations’ aggregated buying power to drive down prices of products in the health care supply chain, including medications. Pharmaceutical companies often give GPOs preferential treatment when shipping drugs in short supply, so GPO member hospitals acquire more of those medications more quickly than non-member hospitals, exacerbating the shortage of those drugs at those facilities. GPOs have been consolidating to further increase their negotiating power with manufacturers, vendors and distributors. 

There are those who blame drug shortages on these large purchasing groups, notably Physicians Against Drug Shortages, a small, nonprofit advocacy group that has been extremely vocal on this subject. 

Purchase Directly From Pharmaceutical Companies

Many of the drugs that have chronically been in short supply are vital, especially for emergency and acute care. More and more health systems have forged direct relationships with drug makers to procure some of those hard-to-get, critically important products, even though one-off purchases may cost more than buying through a GPO or distributor. GPOs are concerned about the increase in direct purchasing contracts, which threaten the long-standing distribution model and the GPO administrative fees that fund those buying groups.

As a last resort, hospitals and health systems sometimes try to import drugs directly from other countries.

Use or Purchase Alternative Medications

When ready-to-administer doses of a medication are unavailable, the drug may be available in a form that requires the doctor or nurse to fill syringes or make other preparations before administering it to patients.

 In many cases, there are medications with similar uses and effectiveness to drugs in short supply that can be used as temporary alternatives. But they often cost more – sometimes many times more – than the unavailable drug. In some cases, doctors who have no other choice may be forced to use older medications that may not be as effective as the drug of choice or may involve more, or more harmful, side effects.

A team of Yale researchers found that using alternative medications in acute and emergency situations raises the risk of medical error, so it may be advisable to familiarize medical staff with the proper procedures, uses and potential side effects of alternative drugs used in acute and emergent care.  

Use Alternative Techniques

When either paralytic agents are in short supply, or cannot be used because of a shortage of paralytic reversal agents, there are alternative techniques such as regional, spinal or epidural anesthesia or nerve blocks that can be used in some cases to reduce the need for paralytic agents. 

Anticipate Shortages at Health Care Facilities

By monitoring hospital pharmacy inventory and tracking drug usage, hospitals and health systems can sometimes predict which drugs will be in short supply and seek alternative sources in advance. If hospitals know that the price of a drug will be going up or going on shortage, pharmacies can sometimes buy up those drugs far enough in advance to maintain a good supply before the price increases or to tide them over during the anticipated shortage. Sheridan meets with its hospital partners’ pharmacies on a regular basis and helps advise them on the best strategies to address specific current and anticipated shortages.

Participate in Advocacy Efforts to Fix the Problem 

The issues causing ongoing drug shortages are complex and interrelated. Arriving at successful short-term and long-term solutions to the drug shortage crisis will likely require the collective input and collaborative efforts of health care providers and facilities, patients, pharmaceutical companies and local and federal government. More physicians need to be vocal advocates for changes to fix the broken U.S. health care supply chain and rethink current regulatory oversight for the ultimate benefit of patients. 

At the national level, Sheridan’s physician leaders are active in the American Medical Association (AMA), the American Society of Anesthesiologists (ASA), the Society of Critical Care Anesthesiologists (SOCCA) and other organizations that have led physician efforts to deal with the drug shortage issue, including lobbying the federal government (including the FDA) and the pharma industry. Although not all of their advocacy efforts have met with success, some have positively influenced federal policy. For example, the FDA’s 2013 Strategic Plan for Preventing and Mitigating Drug Shortages incorporated several AMA policy elements

Physicians can also participate in these efforts at the state level. Many Sheridan anesthesiologists are extremely active in the Florida Society of Anesthesiologists (FSA), a state component society of the ASA, and a number of those physicians have served on the society’s board of directors. 

14 September 2016

ESPN, Health Care Organizations Threatened by New Lower-Cost, More Flexible Alternatives

A recent article in Hospitals & Health Networks pointed out the striking similarities between the disruption of ESPN and the disruption facing health care organizations. ESPN’s dominant leadership position is being threatened by new lower-cost, more flexible entertainment media alternatives, forcing it to re-think its longstanding, wildly profitable business model. The value-based care imperative is causing equally dramatic disruption to the traditional health care delivery model.

ESPN, which styles itself “The Worldwide Leader in Sports,” has long dominated sports media and in 2012 was valued at $40B, making it the world’s most valuable media property. Since then, however, ESPN has been bleeding subscribers, losing four million between the end of fiscal 2013 and the end of fiscal 2015. Streaming media platforms like Amazon Prime Instant Video, Netflix, Hulu and Sling TV have expanded their content, offering more customizable and lower-priced alternatives to cable and satellite TV subscriptions. To remain competitive, cable companies are offering “skinny bundles” that, for the most part, cut out the highest-price premium channels like ESPN (whose per-subscriber fees cost cable operators four times as much as what they pay for other networks). Streaming media and skinny bundles are cutting into ESPN’s revenue stream, and in order to survive this digital disruption the network needs to reinvent its business model and embrace streaming media. As a tentative first step, ESPN cut a deal with Sling TV to be part of its basic $20/month package. But cannibalizing its enormous cable TV subscription revenue with lower-cost streaming offerings is not a profitable long-term strategy, given the high fixed costs of the exclusive content and commentary that makes sports fans willing to pay.

The move to value-based care is creating similar disruption in the health care market. As with cable’s skinny bundles, narrow networks are excluding high-quality providers that can’t cut their costs enough to meet insurers’ and employers’ low pricing demands. Like ESPN, hospitals also have high fixed expenses that are difficult to trim without negatively affecting care. Medicare reimbursements, a major source of revenue, will be at risk under MACRA. In addition to governmental mandates, health care performance is also under scrutiny from 20 major U.S. corporations including American Express, Coca-Cola and IBM, that formed the Health Transformation Alliance, whose collective data analysis of providers’ cost/quality of care value proposition could also put providers’ revenue at risk. As with entertainment media, new lower-cost, more convenient options are entering the market, such as CVS Minute Clinics, virtual visits and urgent care chains. And telehealth is gaining traction, promising further disruption to long-standing health care business models.

Hospitals and other legacy care organizations need to rethink their long-established business models in order to survive these fundamental disruptions to traditional health care. Like ESPN, they are faced with the fundamental challenge of how to provide higher quality, more convenient services at a lower cost. 

22 August 2016

How Video Laryngoscopy Is Shaping the Future of Anesthesiology

In the new Difficult Airway Management issue of Anesthesiology News, three Sheridan physician leaders who are also prominent anesthesiologists discuss the inexorable shift from fiberoptic intubation and direct laryngoscopy toward video laryngoscopy and how that trend is shaping the future of patient care and the practice of anesthesiology.

Sheridan’s Regional Medical Director Dr. Joseph Loskove, Chief Quality Officer Dr. Gerald Maccioli and National Education Director, Anesthesiology Division Dr. Adam Blomberg say that, although direct fiberoptic intubation has widely been considered a gold standard for anticipated difficult-to-intubate (DTI) patients, a lack of consensus among national anesthesia societies on what constitutes best practice in specific situations brings into question whether a universally applicable gold standard for difficult airway management can, or should, exist.

This lack of agreement on clinical best practices makes the inherently difficult job of intubating DTI patients even harder. Further complicating clinical decisions about difficult airway management practices is that as video laryngoscopy becomes the primarily modality of choice, clinicians who intubate patients only occasionally or who have less experience with fiberoptic intubation and direct laryngoscopy become less comfortable using them.

Drs. Loskove, Maccioli and Blomberg emphasize the need to provide anesthesiologists and other clinicians who might need to intubate DTI patients with better and more consistent guidance that helps them make good judgment calls about the optimal modality for a specific application or case, as well as more helpful guidance on when it might be advisable to change to an alternative modality in the event of complications. The authors also stress the importance of helping anesthesiologists maintain or develop their level of comfort using conventional laryngoscopes, so that they maintain a complete and comprehensive set of laryngoscopy modalities in their DTI tool kits and are comfortable switching from video laryngoscopy to fiberoptic intubation or direct laryngoscopy if the technology fails them.

The article concludes with a discussion of the importance of optimizing and implementing system-wide protocols, such as the extremely successful difficult-to-intubate protocol that Dr. Loskove installed throughout the Memorial Healthcare System (MHS).

Read more about the perspectives of these renowned anesthesiologists and physician leaders in their Anesthesiology News article, The Shift Toward Video Laryngoscopy: The Good, the Bad, and the Future.

15 August 2016

Six Physician Communication Strategies to Increase Patient Engagement and Improve Outcomes

Effective physician-patient communication that builds trust and a shared sense of responsibility for the patient’s care is an increasingly important skill for physicians. Doctors whose communication fosters patient engagement has been linked to a wide range of benefits, from increased patient satisfaction, trust and higher quality of care to better patient adherence to treatment and improved physical outcomes. Communication skills are especially important in a hospital setting, which patients often perceive as more impersonal than a visit to their primary care physician’s office.

The challenge is that while the need to involve patients in decisions about their own care continues to grow in importance, the current health care environment – including shorter hospital stays, more complex medical care and a drive for efficiency – makes it harder to achieved good communication among providers, patients and family members.

The Negative Effects of Poor Physician Communication on Patient Experiences … and Outcomes

A 2015 study published in PLOS ONE synthesized qualitative studies exploring patients’ experiences in communicating with a primary care physician to identify the determinants of positive and negative experiences in physician-patient communication and their subsequent outcomes. It found that, overall, primary care physicians’ communications create more negative than positive patient experiences. Patients report that physicians usually lead consultations and sometimes in a paternalistic manner – deciding on the treatment plan without engaging the patient in a conversation about care decisions, asking too few questions or too many closed-ended question, and rushing through explanations of the patients’ illnesses while using complicated, unfamiliar medical jargon. Doctors often orient conversations toward physical symptoms without leaving room to discuss psychosocial aspects related to the condition. As a result, patients say they feel powerless, vulnerable and intimidated and, therefore, less likely to engage in their own care decisions by asking questions or volunteering psychosocial or other information that might affect their diagnosis or treatment. Those who attempt to address psychosocial issues proactively report being dismissed.

Patients say these negative experiences leave them feeling not only helpless, frustrated, unheard and unrecognized but also unmotivated to comply with their treatment plans.

While this study focused specifically on primary care doctors, these problems can be exacerbated in a hospital setting, where a physician-patient relationship may not have been established.

Communication Skills That Promote Patient Engagement

Patients also shared the communication-related skills they value most in physicians:

  • Empathy.
  • Careful listening.
  • An open mind.
  • Friendliness.
  • Compassion.
  • A genuine interest in the patient.
  • Attentiveness.
  • Willingness to ask questions and initiate conversations.
  • Investing time and effort to educate patients and make sure they understand the illness.

These skills are key to fostering collaborative, two-way communication and building trust and mutual respect – things that can provide important contextual information and enable doctors to do a better job of tailoring care and fostering patient engagement.

Cultural Barriers to Effective Communication

Ultimately, whether patients experience a physician’s communication with them as positive or negative is heavily influenced by the context of a patient’s individual background and values. Some of the ethnic minority patients report experiencing additional communication difficulties resulting from language barriers, discrimination, differences in values and beliefs, and acculturation-related issues.

The study offers several examples of how acculturation affects physician-patient communication. One such example is that Hispanic migrants to the U.S. say they need to develop a warm relationship with their physicians before they feel safe sharing private information, while U.S.-born Hispanics attach less importance to developing warm relationships with their doctors because they appear to understand that the physician’s primary role in this country is to heal.

Interestingly, patients who need to consult with informal interpreters during medical visits say those consultations make them feel embarrassed, guilty and uncomfortable. And, not surprisingly, the presence of an informal interpreter not only inhibits patients from discussing sensitive or mental health topics but also makes disclosing intimate information difficult or impossible.

Six Ways to Improve Physician-Patient Communication and Engagement

Solicit Relevant Psychosocial Contexts

Encourage patients to talk about psychosocial factors that might be related to their condition. Try to provide a nonjudgmental atmosphere to help make them comfortable talking about difficult personal issues.

Tailor Communications to Cultural Contexts

Develop a cultural awareness and understanding of the populations you serve and tailor communications appropriately to each patient’s cultural, values- and beliefs-based context to avoid inadvertently giving offense or causing mistrust.

Educate Patients on Care Best Practices

In a recent article in MedPage Today, Dr. Catherine Polera, chief medical officer for Sheridan’s Emergency Medicine division, describes how she uses effective communicate to bridge gaps in patient expectations. For example, patients who are diagnosed with bronchitis often expect a prescription for antibiotics, yet acute bronchitis is usually viral and, therefore, usually should not be treated with antibiotics. She finds that explaining the reason for her decision not to prescribe an antibiotic in that situation, using easy to understand language and showing patients evidence that supports her decision – using online sources they trust – helps educate patients and increase their satisfaction with the care she provides.

Educate Patients About Responsible Antibiotic Stewardship

This is also an opportunity to educate patients not only on their diagnosis but also on the evolution of antibiotic-resistant superbugs and the importance of responsible antibiotic stewardship on the part of both doctors and patients to slow that evolution.

Provide Compassionate, Personalized Care and Reassurance

A great example is radiologists Dr. Lynda Frye and Dr. Orna Hadar at the Jupiter Medical Center’s Margaret W. Niedland Breast Center, who understand that breast cancer screening is often an intimate, stressful experience for patients. To engage patients in their own care, both these physicians build patient relationships based on honest communication and trust, providing timely information and reassurance during what can be a frightening time. They read mammogram imaging immediately and discuss the results with patients. They thereby connect directly with patients and eliminate the dreaded callback to inform patients that they need to take more images. If more images or biopsies are necessary, Dr. Frye and Dr. Hadar will order them at that appointment. Additionally, they insist on delivering news to patients themselves to demonstrate their total commitment to the patient. Their compassionate, personalized care builds trust and encourages their patients to return for annual breast cancer screenings.

Provide Online Information Resources to Educate Patients and Set Expectations

Providing easily accessible, curated, topic-specific information can help reduce patients’ anxiety and properly set their expectations about medical conditions, recommended treatments and upcoming procedures. A good example of the latter is Sheridan’s Anesthesia Patient Education Portal, which not only explains the different types of anesthesia, the roles of anesthesia care team members, and what patients should expect before, during and after surgery, but also provides guidance on the types of questions patients may want to ask the anesthesiologist during the preoperative evaluation. Setting expectations, particularly around pain management, also can have a positive impact on patient experience and satisfaction

9 August 2016

Technology Innovations That Will Transform the Future of Radiology

Advances in technology over the past two decades, from PACS systems to voice recognition software, have enabled significant improvements to efficiency and, in turn, patient care in the field of radiology. New technology promises to fundamentally change the practice of radiology, thanks in part to IBM’s recently formed Watson Health medical imaging collaborative. In a new article in Healthcare Tech Outlook, Dr. Glenn Kaplan, Sheridan Healthcare’s VP of Offsite Radiology Services, talks about how Sheridan and other members of this collaborative are working to leverage Watson’s sophisticated cognitive computing and cognitive imaging capabilities to help make radiologists better diagnosticians and physicians.

It’s common for referring physicians to provide radiologists with very minimal patient information on the order sheets, which often are missing relevant information that can affect the accuracy of the readings. This problem is frequently exacerbated by a lack access to that information because of system interoperability issues. But those issues could become irrelevant in the foreseeable future, thanks to the work of the new IBM Watson medical imaging collaborative. Watson is “a technology platform that uses natural language processing and machine learning to reveal insights from large amounts of unstructured data.” Members in the collaborative plan to make the most of its unparalleled cognitive computing capabilities, training it to help doctors provide more patient-specific care as it creates a continually growing knowledge base that can be used to improve care for broader patient populations as well as individuals.

One of the initiatives will be training Watson to detect abnormalities in radiology images, including things like subtle fractures that even a very experienced radiologist might easily miss and that could have major implications for the patient’s health, quality of life, and even life expectancy. Another is teaching Watson to prioritize cases that require emergent care. Ultimately, the partners hope to help Watson learn to understand and extract insights from X-rays, CT scans, MRIs and a variety of other unstructured imaging data, combine those insights with patient and clinical data from a broad range of other sources, and pull together the most relevant information for each case to help doctors make more effective and more individualized care decisions for their patients.

Learn more about the exciting work of the IBM Watson Health medical imaging collaborative that will pave the way for a new era of personalized patient care in Dr. Kaplan’s article “Technology Innovations That Will Transform Radiology and Patient Care.”

2 August 2016

Better Pain Control Halves Length of Stay for Westside Regional’s Joint Replacement Surgery Patients

Jonathan Katz MD, a Sheridan Regional Medical Director and Chief of Anesthesiology at Westside Regional Medical Center in Broward County, Florida, and Eric Schiffman, MD, a board-certified orthopedic surgeon and fellowship-trained hip and knee replacement specialist, are the featured guests on a new episode of Dateline Health, a television show produced by Nova Southeastern University (NSU). Drs. Katz and Schiffman spoke with Fred Lippman, R.PH., Ed.D., NSU’s Chancellor of the Health Professions Division and the host of the show, about their extremely successful rapid recovery pathway at Westside Regional, which has significantly improved post-operative pain management and cut the average hospital stay for orthopedic surgery patients in half.

When Dr. Katz first arrived at Westside Regional about eight years ago, he identified opportunities to further improve the hospital’s already robust orthopedic joint replacement program. Back then, “total joint replacement was a tough operation. Patients would be in the hospital for five to seven days,” explains Dr. Katz. “Pain management was one of the major issues,” he says, because the pain medications used at the time had a number of side effects including nausea, vomiting and delirium that prevented patients from going home.

Dr. Schiffman made some recommendations that Dr. Katz discussed with the hospital’s team of orthopedic surgeons, whose collaboration was an important part of the new pathway’s success. Adaptations to the practice were made based on the best available evidence in the relevant medical literature. Then, they looked at ways to improve the experience of patients undergoing joint replacement surgery. Instead of looking at how patients were doing immediately following the operation, the doctors took a more comprehensive look at the entire patient experience and how it could be improved.

Together, they developed a start-to-finish pathway that begins three to four weeks prior to the scheduled surgery, when there is a discussion with the patient to set appropriate expectations and explain his or her role and responsibilities (with regard to pain management, physical therapy, rehab, etc.) in making their overall experience, recovery and outcome as positive as possible. The pathway includes the use of a multi-modal technique throughout the process, beginning with preemptive analgesia that includes medications given to patients in a preoperative holding area as well as nerve blocks administered by an anesthesiologist. At the time of surgery, Dr. Schiffman administers a non-narcotic, anesthetic “cocktail” around the surgical site that combines different medications to help control the pain, reduce blood loss and decrease inflammation.” Post-operative pain is managed effectively with minimal amounts of narcotics.

Dr. Schiffman, who hasn’t used a pain pump in five years, says improvements to the pain management process have dramatically enhanced recovery times and patient’s overall experiences with joint replacement surgery. Patients who had previous joint replacement surgeries are “shocked” by how little pain they have the next day and how quickly they are able to leave the hospital and return home.

Standardization and consistency are key aspects of the process at Westside Regional Medical Center, where joint replacement surgery patients now typically go home in three days or less. And bilateral hip surgeries are now an option, thanks to the hospital’s approach that makes it easier for patients to get around independently immediately after the surgery.

To learn more about these and other innovations in joint replacement surgery at Westside Regional, watch the entire interview with Drs. Katz and Schiffman.

28 July 2016

Drs. Drozdow and Sell Honored by Florida Society of Anesthesiologists

The Florida Society of Anesthesiologists selected Sheridan’s Chief Clinical Officer, Gilbert Drozdow, M.D., M.B.A., and Brence Sell, M.D., a Sheridan anesthesiologist who sits on the FSA’s board, to receive awards at the FSA’s 2016 annual meeting at The Breakers in Palm Beach, Florida, that took place June 10–12.

Dr. Drozdow was honored with the Florida Society of Anesthesiologists’ highest award, the Distinguished Service Award. This award is the highest tribute the Society can pay to an FSA member for outstanding clinical, educational or scientific achievement, contribution to the specialty and exemplary service to the Society.

Dr. Drozdow joined Sheridan in 1987 as an associate clinical anesthesiologist and has been a director since 1991. After the company’s major reorganization in 1994, he served as Senior Vice President, President of the Anesthesiology Division and then Executive Vice President for the company. Dr. Drozdow holds a Bachelor of Arts degree in Biology from Brandeis University and received his medical degree from the New York University School of Medicine in 1983. Before completing his residency in anesthesiology and fellowship in cardiovascular anesthesiology at New York University Medical Center/Bellevue Hospital in 1987, he also completed a fellowship in pain management at the University of California Los Angeles Medical Center in 1986. Dr. Drozdow continued his education at the University of Miami School of Business Administration, earning a Master of Business Administration (MBA) degree in 1996. He continues to maintain his Board Certification in Anesthesiology.

Dr. Sell was the first recipient of the society’s new Presidential Engagement Award, created to recognize a physician anesthesiologist who is an “unsung hero,” making a tirelessly commitment to the profession without asking for anything in return.

Dr. Sell, who is also a clinical assistant professor at Florida State University College of Medicine, is the only anesthesiologist in North America who is Board Certified by the American Board of Anesthesiology, the National Board of Echocardiography and the American Board of Neurophysiologic Monitoring. He graduated from the Emory University School of Medicine and completed his residency training in Anesthesiology at Water Reed Army Medical Center. He subsequently completed a fellowship in Neurosurgical Anesthesia at Johns Hopkins Hospital and then served on active duty in the U.S. Army. Following his military service, Dr. Sell has been in private practice as an anesthesiologist in Florida.

Please join us in congratulating Drs. Drozdow and Sell on being chosen by the FSA to receive these prestigious awards!

27 July 2016

The Challenges of Staffing a Rural Hospital Successfully

Population health management is a challenging proposition in any location, but especially so in rural areas, which comprise nearly 20 percent of the U.S. population and more than 95 percent of the country’s land. Health care resources are more limited and the population is more spread out than in urban settings. The patient base at rural and nonurban hospitals also tends to be smaller, older, poorer, and less healthy than that of urban hospitals, which means there is little opportunity to mitigate financial risk. The inability to take advantage of the economies of scale enjoyed by urban healthcare systems affords little opportunity for cost reduction. Add in shrinking Medicare reimbursements, and it becomes hard for a rural hospital to keep its head above water.

Financial constraints often require rural clinicians to provide specialty care outside their primary areas of expertise. Obstetrics, for example, is an expensive and usually money-losing proposition for rural hospitals. According to a study in the Journal of Rural Health, hospitals with fewer than 240 births per year were more likely to have family physicians and general surgeons (rather than obstetricians or midwives) attending deliveries. Having physicians flex like this can result in trade-offs in quality and safety.

Insufficient staffing scenarios that broaden and increase rural physician’s responsibilities make their jobs even more demanding and stressful. Hospitals that don’t give their physicians ongoing appreciation and recognition risk losing these crucial resources.

If these challenges sound familiar, here are some strategies to consider:

  • Provide education on chronic disease prevention and self-management. This can help improve population health and smooth out demand for its limited resources. Consider participating in the National Council on Aging’s Better Choices, Better Health® programs, which are available to participating organizations both as workshops and online.
  • Join forces with other hospitals. Jane Bolin, BSN, JD, PhD, senior editor of Rural Healthy People 2020 and director of the Southwest Rural Health Research Center at Texas A&M University, said in an article in HealthLeaders magazine that “Dire financial straits have prompted many rural and nonurban hospitals to surrender some of their cherished independence in exchange for affiliations that provide economies of scale and access to capital and services.” Many rural hospitals find it more efficient to collaborate with external organizations to provide a broader range of services via referral. The partner hospitals can then distribute Medicare reimbursements to everyone who participates.
  • Use LEAN principles to improve physician alignment and engagement and streamline business processes. The Kaizen business process improvement methodology is a core aspect of Sheridan’s management philosophy. Our partner hospitals have seen dramatic improvements in physician engagement, quality of care, speed and productivity after holding Kaizen events to collaboratively identify and implement successful solutions to challenges such as high cancellation rates for anesthesiology, excessive admittance delays and long IV-tPA cycle times.
  • Engage a performance-driven physician services provider to achieve economies of scale and deliver more effective and cost-efficient care. A professional physician services provider can help you reduce waste and overutilization, improve the quality of care and efficiency of its delivery, and help bring physicians into alignment with your value-based health care strategy. Sheridan provides staffing, performance-driven management and best-practice processes for our partner hospitals' key departments and practices, including Emergency Medicine and Critical Care, Anesthesiology, Radiology, OBGYN, Neonatology, Perinatology and Pain Management.

If you’re interested in finding out how Sheridan can help you overcome the staffing challenges at your hospital, learn more about our cost-effective, industry-leading health care solutions that include physician staffing, LEAN-based process improvement and infrastructure support. 

21 July 2016

Key Considerations for Performing Outpatient Total Joint Replacements at Ambulatory Surgery Centers

According to a recent article in Becker’s ASC Review, orthopedic procedures, especially, total knee and hip replacement surgeries, are among the most popular surgical services performed at ambulatory surgery centers (ASCs). The publication interviewed Sheridan anesthesiologist Cameron Howard, M.D., who described some of the key considerations in doing these types of procedures as outpatient surgeries successfully.

Dr. Howard explained that although it is much more cost-effective to do these procedures on an outpatient basis, it is desirable for some patients – e.g., middle aged, non-obese, with no significant medical problems – but not for all. For example, an inpatient setting may be preferable for patients who are morbidly obese, brittle diabetics and patients with cognitive decline.

The other key consideration is whether the family has a support system in place, “with family or friends to help them with ambulating, transferring and transporting them to outpatient rehab,” Dr. Howard said. Inpatient surgery may also be a better option for patients who don’t have that type of support system.

Dr. Howard also said that a comprehensive program that includes extensive preoperative training is required for successful outpatient total joint surgeries. Patients need understand that they will have some pain, and must be educated about the complication risks related to joint replacements.

He also discussed the role of anesthesia and pain management in outpatient joint replacement.

Read more about Dr. Howard’s views on this topic in the Becker’s ASC Review article, “Outpatient TJR rests on these 2 pillars — Sheridan's Dr. Cameron Howard weighs in.”