Integrated Practice Units and the Perioperative Surgical Home: What’s on the Horizon? Q&A with Karl Koenig, MD

Karl Koenig, MD, MS is the Medical Director for the Musculoskeletal Institute at UT Health Austin. He specializes in treatment of hip and knee arthritis including both primary and revision surgery. Dr. Koenig has a special interest in the treatment of periprosthetic fractures and joint infections.

Dr. Koenig is a Central Texas native who received his undergraduate degree from MIT and his medical degree from Baylor College of Medicine. After that, he moved to New Hampshire where he earned a Master of Science from Dartmouth College. While at Dartmouth, Dr. Koenig was one of the architects of the GreenCare Pathway, a quality improvement initiative around total joint replacement, and lead the Division of Adult Reconstruction at Dartmouth-Hitchcock Medical Center.

The following is a Q&A that TOA recently conducted with Dr. Koenig.

TOA: We hear a lot about an emphasis on “value-based care” in the Department of Surgery at Dell Medical School. How have you and your colleagues changed the way that you all deliver musculoskeletal care?

KK: For us, it’s really been about looking at a different incentive structure and how that might change the way we are able to deliver care in this country. We are very lucky in orthopaedics to have excellent surgeons and physicians throughout our field and around the world. However, the development of the fee-for-service system in the U.S. has created a world where all of the financial incentives in healthcare are directed toward imaging, testing, and procedures. The non-surgical care that we provide is not really valued, even though it may be the best thing for the patient.

So, spending the time to explain to a patient why an unnecessary MRI should be avoided is doubly disincentivized. First in the time it takes to explain to the patient, and then in the lost revenue from not doing the study. This results in an environment where the ethical physician who wants what is best for their patient generally has to fight upstream to do the right thing. We are trying to fundamentally change that by incentivizing providers on the value they provide to patients. As an orthopaedic surgeon in a value-based environment, I lead a multidisciplinary team of providers who are focused on a certain set of conditions and share a common measurement platform. We are incentivized to measure our outcomes as well as costs and succeed when we create value for our patients. By flipping this dynamic on its head, we create a system where the financial success of the provider is aligned with the value created for the patient. The team is focused on helping the patient to get and stay healthy rather than just delivering care for an isolated part of their anatomy.

TOA: When it comes to value-based care, we often see an emphasis on THA/TKA. But what about other specialties within orthopaedics?

KK: Great question. As arthroplasty surgeons, we have gotten used to being the pilot program for the majority of improvement efforts and attempts at payment reform. This comes from the fact that THA and TKA are popular procedures (both in the top ten items on national Medicare spending), highly successful, and are more measurable than lots of other interventions. We have learned to embrace this work because it gives us the opportunity to constantly evolve and improve the delivery of care to our patients.

However, these concepts are easily demonstrable in all parts of the musculoskeletal system. Shoulder issues such as rotator cuff disease, osteoarthritis, and multiple other less common diagnoses affect a large number of patients every year. These conditions and their treatment are largely dictated and differentiated by expert history taking and diagnosis, yet much of the initial care and diagnostic testing is performed by providers who have very little training in this area. I would venture to say that the majority of people who present to a shoulder expert have already had an MRI by their primary care provider beforehand, when the majority of shoulder conditions do not require an MRI in the diagnosis or treatment algorithm. If patients who present with a shoulder problem were able to access an integrated practice unit (IPU) team initially, then there are huge opportunities to create better outcomes and save resources simultaneously. The value creation is nearly automatic. I could make the same argument for the care of back and neck pain, carpal tunnel, tennis elbow, etc. The list goes on.

TOA: Patients at UT Dell’s orthopaedic department work with a perioperative surgical home. What does that entail?

KK: For patients who receive care in our IPU, many will benefit from surgery. In fact, one of the fundamental differences of a value-based structure is that it removes the “checkboxes” one must go through in order to have a patient authorized for surgery. If we see a patient who is 65 years old with grade 4 osteoarthritis of the knee whose pain and function scores demonstrate severe disability, then the highest value approach is often to proceed with TKA. However, in the FFS structure, the patient will need to demonstrate multiple “failed” conservative measures such as PT, NSAIDS, and Injections. If surgery is really what the patient needs, then these represent wasted resources and non-value added care. In a value-based structure, the patient and team can work together in a shared decision-making process and then carry out the best treatment plan without those unnecessary administrative hurdles.

That said, for patients who choose to have surgery, we are incentivized to minimize complications and the cost of that surgical episode. That is where the perioperative surgical home comes in. This is a team composed of surgeons, anesthesiologists, hospitalists, nurses, and support staff who work to prepare patients for surgery and manage their care through the transition from presurgical workup, education, home preparation, and early follow up to eliminate the fragmentation of care that patients experience perioperatively. Obviously, this level of resource investment makes the most sense for larger procedures and patients with higher levels of comorbidity, but the amount of involvement can be titrated. Coupled with this in a decision by the surgeon to allow appropriate time for preparation and optimization prior to elective procedures in order to realize the benefits. For example, when one of our patients elects to pursue THA or TKA, we explain the benefits of the perioperative surgical home and set expectations for the process. Their date of surgery is not set on the day of booking because it will depend on the results of their initial health screening. They are contacted by the PSH with 24 to 48 hours for the initial questionnaires which give a complete health history and small battery of evidence-based risk assessments. These scores, in the context of which procedure they are having, will determine the level of preoperative workup required. If they get a “green light”, then they just come for baseline labs and joint replacement class. They are free to book their surgery ASAP. If they need to stop smoking, tend to 3 dental abscesses, and get their diabetes management optimized, then the PSH works with them and their PCP to accomplish these things and we hold off on booking surgery until it’s right time for that particular patient. We also give them a program of “prehabilitation” exercises to begin working on in order to get in shape for their post-operative recovery. After surgery, this same team is involved in carrying out the discharge plan and frequently follows up with the patient, home health, PT, or SNF personnel as the case may be. The PSH can help the surgical team to identify issues that patients are having and avoid unnecessary ER visits or readmissions that result from a lack of communication. In those rare patients who go to SNF, this also allows us to make sure they don’t have unnecessarily long length of stay in those facilities.

Overall, the fundamental difference here is looking at the surgery as an investment by the patient in their health and scheduling that intervention at a time when they are ready to achieve the best outcome at the lowest risk of complications, rather than when I have available operative time. There are obvious exceptions when the surgery is more urgent such as impending fracture or a patient with an infected prosthesis in revision situations and we deal with those according to the specific situation. But in the elective TJA setting, this approach is very sensible and makes it easy to do the best thing for the patient. As anyone who’s been involved in a TJA bundle will tell you, this type of preparation and coordination leads to decreased LOS, complications, and unnecessary readmissions. Most importantly, it improves care for our patients by eliminating fragmentation and extending the perioperative care expertise throughout the perioperative episode. When the patient is recovered from their surgery, then they are transitioned back to the care of the PCP smoothly and with good communication.

TOA: How do you all track patient outcomes?

KK: We use a combination of metrics, but really try to focus on the value we are bringing to patients. At this stage of our understanding, the best metrics we have for the patient’s pain and function are validated patient-reported outcomes measures (PROs). The way I look at it is that musculoskeletal providers are in the business of improving a patient’s pain and function, but for many years we have only really measured those items in research studies. Your PCP wouldn’t try to manage your hypertension without measuring your blood pressure, right? Similarly, we have to objectively measure patients pain and function in order to know how we are doing. At the same time, we also pay attention to other metrics that are more traditional such as infection rates, length of stay for procedures, return to work and return to activities. The big difference is the emphasis we have on measuring what we do and the whole care team measuring themselves on that same platform. It’s not just how the surgeon is doing. It’s how the multidisciplinary team is doing in providing care for this condition. If we are improving PROs for patients at a lower cost than the payer spent last year on fragmented care of the same type of patient with the same condition, then we are rewarded for that.

TOA: How are you all addressing the opioid issue?

KK: Upfront. Giving patients the information and evidence that is driving the concerns nationally. We let them know that we want to help control their pain, but have to keep these concerns about addiction and the potential consequences of it in mind while doing so. Our team has worked together with pain management experts to develop a specific, evidence-based policy for the handling of narcotic medications in patients with musculoskeletal issues. The credit for this really has to go to Mark Queralt, MD and David Ring MD, PhD. It was a lot of work, but has been a major benefit for our teams and our patients. I would venture to guess that most Orthopaedic surgeons have developed their own personal pain control algorithms in the same way I did. We learned from our mentors in training and then adopted some behaviors. Then we refined those over the course of time through experience and issues that occurred in some of our own patients. However, in my own practice, I had probably veered away from best evidence and standardized protocols over the course of time. I certainly didn’t feel I had enough expertise to properly manage some of the chronic pain patients on baseline narcotics that I was seeing.

By adopting this policy based on good evidence and best practices, it has gotten our whole team on the same algorithm and protects our patients. The policy behooves us to discuss it upfront with our patients, set expectations, and “depersonalizes” the conversation. It’s not that “Dr. Koenig doesn’t want to give you more narcotics because I’m not sympathetic to your pain”, but “We have this policy set up for your protection and we have to adhere to it. Let’s talk about some other options.” It also gives us the opportunity to proactively educate about the side effects of narcotics and pre-emptively address nausea, constipation, and sedation. For patients who are on chronic narcotics prior to seeing us, we can pro-actively develop a plan in conjunction with their pain management specialist about perioperative management and transition back to their care after surgery. In the end, our team has seen impressive changes in our approach and anecdotally we have not seen much difference in patients’ perceptions of their pain management.