The Business of Arthroplasty: Understanding the Horse Out of the Barn

Even as recently of 5 years ago, surgeons and providers spent most of their time focusing on improving outcomes for patients solely because it was the right thing to do…it was part of an ethical obligation they made when they took that famous oath. The Institute of Medicine had declared previously that to err is human, and the expectations of patients, payers, and providers centered on the individuality of each patient case and the acceptance that medicine itself was an art and errors unavoidable. Conferences focused on surgical techniques and medical topics, often viewing business or financial discussions with disdain and a sense of ill-defined moral medical corruption. Nonetheless, for better or worse, times are rapidly changing. Medical providers must now focus on the business of health care, along with a whole new bowl of alphabet soup, including important acronyms such as MIPS, MACRA, PQRS, QRUR, CJR, BPCI, CIN, APM, PHO, and ACO. Health care cost is consuming an unreasonably large portion of the nation's gross domestic product while placing added economic burdens on physicians and their patients, all the while not showing outcomes consistent with value compared with many other national systems. With total joint replacement being one of the early-targeted procedures in this evolving health care environment, knee surgeons will benefit from developing a critical knowledge of health care reforms and their financial implications. I believe that this special section in the Journal of Knee Surgery may help you get a head start.

In an article entitled “Evolving beyond Craft Surgery Is Both Inevitable and Essential” by Dr. Jason Scalise, you will learn that health care, much like other industries striving for six sigma results and the elimination of variation and avoidable errors, is on a new path. Given the increasing emphasis in health care on improving outcomes, reproducible results, and creating value for the patient, orthopedic surgery in particular must necessarily continue to progress away from an individualized and a surgeon-specific technical craft and toward a highly automated and computer-integrated process in which surgeon and digitized systems interact to provide the most reproducible and consistent outcomes possible. This work will get you thinking about just how that may look.

In the second article written by physicians and consultants, “Contracting Strategies for Arthroplasty—Bundles to Population Health,” we lay out how the fee-for-service payment system is unsustainable and that this fact has led the Centers for Medicare and Medicaid Services (CMS) to use new value and risk-based contracting strategies on a population health and episode of care basis, with programs such as the Bundled Payment for Care Improvement and the Comprehensive Care for Joint Replacement. These trends are already forcing hospitals and physicians to align to improve quality and reduce costs through new structures such as accountable care organizations, co-management programs, and gain sharing. As these programs are now becoming mandatory, surgeons must understand the structural aspects of these arrangements and the levers available to optimize the likelihood of winning. I hope that this manuscript provides you such a framework for success.

In “Reimbursement Based on Value in Knee Surgery: What You Need to Know about the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015,” Saleh et al will answer key questions about new legislation around reimbursement and publicly reported scoring systems. The Medicare Access and CHIP Reauthorization Act (MACRA) represents a cohesive movement toward value-based payment reform and contains several rulings that require detailed attention by knee surgeons. In this manuscript the authors provide a contextual framework of health care legislation that has led to the formation of the current health policy, and present a comprehensive summary and update on the Merit-Based Incentive Payment Systems (MIPS) and Alternative Payment Models (APMs) reimbursement models.

Last, everyone talks about registries. However, it often is unclear how to use these data in a meaningful way as a practicing physician, and especially how to harness such information to improve reimbursement or redefine your relationships with payers. In “Arthroplasty Registries: Improving Clinical and Economic Outcomes” written by Drs. Max Courtney and David Markel, you will hear how a registry and partnerships between surgeons, insurers, and health systems have improved on earlier administrative datasets from Medicare to measure quality and outcomes. They will show how participation in state and national registries can help surgeons and hospitals gain a financial advantage in several insurers' quality programs and alternative payment models.

I do hope that you find these four manuscripts helpful in your inevitable journey down the road of transition from volume-based to value-based payments. I commend the Journal of Knee Surgery for its proactive interest in these critically important topics and their recognition that understanding this material is, perhaps, a matter of practice survival, if not just one of practice success.