The shift of total joints and orthopedic cases from the hospital to the ASC is becoming more predominant based on several driving factors such as increased surgeon autonomy, favorable outpatient payer policies, advances in medical technology, and improved health literacy among the patient population. Surgeons who were initially undecided are now looking for ways to capitalize on this shift. However, with all the critical requirements to establish a successful outpatient total joint program, many are left wondering where to begin.
To better understand the driving factors for this shift and what is essential to establish a successful outpatient total joint program, Becker’s ASC Review recently met with Nicholas B. Frisch, MD|MBA*, an orthopedic surgeon specializing in minimally invasive, complex and revision large joint replacement. Dr. Frisch was an early adopter of outpatient total joints; he was still completing his residency in 2012 at Henry Ford Hospital in Detroit, Mich.,when he began to realize the number of inherent benefits of performing total joint procedures in a freestanding surgery center. He began to lay the foundation for his own company during his fellowship at Rush University Medical Center in Chicago and opened his first ASC upon completion of his fellowship in 2017. Today, Dr. Frisch is involved in building, managing and operating many total joint-focused ASCs across the Detroit metropolitan area.
A Win-Win-Win Scenario
We asked Dr. Nicholas B. Frisch what makes total joint cases in an ASC more attractive than performing them in the hospital from the perspective of a surgeon, patient and payer.
"From a surgeon’s viewpoint, there are many advantages to operating in an ASC. First, there’s the opportunity to be involved from a business standpoint. Speaking candidly, there are opportunities for physicians to partner with each other, management companies, or in my case my hospital that I’m affiliated with. So there’s a financial benefit from that standpoint. From the other side of it, you have a lot more autonomy; for example, we use ROSA robotics in our ASC, but there have been some challenges implementing that in our hospital. For me it was only a two-week process to coordinate getting a ROSA with my other surgeons, and now I can use ROSA very easily in the outpatient setting. There’s also a lot of freedom for how you want to schedule your cases, what you can do to create great patient experiences, and many other advantages related to the freedom gained by operating in an ASC.
"There are also a lot of benefits from the patient’s side, which has been an even bigger change with COVID. Everyone has their own approach, but my approach was you can either be operated on at the freestanding ASC and go home the same day, or you can be operated on at the hospital and go home the same day as well. This was largely a selection question for me because you had one group of people who would say, ‘I definitely want to go to the hospital.’ That was fine as it may have been the best option for them, but then on the other hand you had this group that would say, ‘Oh no, I don’t want to go to a hospital – I definitely want to go to the surgery center.’ With COVID, the answer to that question has changed dramatically in the sense that most patients are actually coming in and asking to have their surgery performed in the ASC away from a hospital, before you can even discuss site-of- care options with them.
"Lastly, we have the payers where we continue to see more push on the authorizations. They’re saying if a procedure can be done in an ASC they want it to be done in an ASC, due to cost of care, reimbursement, great outcomes, etc.
"I think things will only progress further in favor of procedures being performed in an ASC versus a hospital, especially from the patient side where word continues to get out in the community as people go through the process and have such positive experiences, there’s a positive shift culturally where people are just more open, interested and educated on the benefits of outpatient surgery being faster, more convenient and producing great outcomes.1 I do not see any scenario where the shift to have more procedures done in an outpatient environment will go back the other direction; I believe it will only accelerate," said Dr. Frisch.
The Mindset for Outpatient Success
Ambulatory surgery centers are complex small businesses – each with their own unique challenges: lower reimbursements compared to hospitals and hospital outpatient departments, limited capacity for storage, staff and sterilization, and a plethora of workflows and communications that must be streamlined to ensure the ASC remains as efficient and profitable as possible. The goal is to combat these challenges all while delivering excellent patient care and improving outcomes. Even with a business degree and healthcare operations experience, all these added responsibilities can be daunting to a surgeon who traditionally has only been responsible for the clinical aspects of a surgery.
We asked Dr. Frisch what advice he would give to someone who is responsible for bringing total joint cases to a new or existing ASC, or perhaps has already started their program, but is looking for ways to improve.
"Surgeons need to be thinking about the things that are happening in the hospital that they don’t normally see,” he said. “Things like the physical therapy protocols, the medication formularies, what medications are available, even if you don’t routinely use them, but that you may need in some circumstances. Instrumentation is a big thing. You may know exactly what you do for a routine joint replacement, but at the hospital you have every instrument available that you may need if something goes wrong; if something critical drops, do you have another available? You need to be thinking about the whole process from front to back. This includes sterilization capacity, postoperative education and protocols that the hospital did that you may not have even realized, such as day- one postop check-in calls and all the check-ins that happen routinely on the inpatient side but not on the outpatient side without putting them in place."
Selecting the Right Partner is Everything
"The most important thing is having a partner that provides a truly comprehensive solution for all of your needs in the ASC," said Dr. Frisch. "For me that partner is Zimmer Biomet. I don’t see Zimmer Biomet as an implant company. I see them as a true partner that brings comprehensive solutions for the entire spectrum of care. That’s a big difference.
"For example, whether planning an outpatient total joint program from the outset or trying to improve upon an existing one, Zimmer Biomet’s Accelero Clinical Consulting Services can help with things like planning the overall infrastructure, perioperative, patient and care team workflows, data collection, creating program documents – including documentation for effective payer contracting – and many other crucial tasks. If you don’t want to involve a management company, or potentially even if you do use a management company, Accelero is a much-needed service to get your surgery center where you want it to be a lot faster.
"Also, in our surgery centers we use the ZBEdge Connected Intelligence Suite, so the patients start with mymobility, which is fantastic for both pre- and postop patient-level data collection and communication. We also use ROSA robotics and the OrthoIntel Intelligence Platform, so with the data being captured and combined from the entire spectrum of care, uncovering clinical insights to help inform better decisions and ultimately better outcomes is effortless. We have also recently started using the mymobility telehealth platform and that has also made a big difference in being able to manage a lot of the routine postop check-ins remotely. We use mymobility as our remote patient monitoring program overall and are able to closely monitor each patient to know if they are on track or potentially deviating from what’s expected at each stage of the postop recovery process.
"Something else that has made a huge difference for limitations around storage and sterilization is the Efficient Care offering, where we worked with Zimmer Biomet to narrow down the concise instrumentation needed for a procedure. With Efficient Care, when we go into a surgery, we are not opening full trays but only what we need to do the trials and perform the procedure. Our reps know exactly what instruments I need to do each of my cases, and we have a redundant set of these in our Efficient Care cart that are individually peel-packed so that if a retractor drops, we have a backup readily available. This has been huge for us, as we are down to just one tray for all of our basic instruments. Those are the kinds of things you really want.
"Lastly, on the management side for our other facilities, Zimmer Biomet can help with all the OR integration, the lights, the booms, and a lot of other needs. Having all of these solutions from Zimmer Biomet as our ASC partner makes everything easier for me, my team, our surgery center overall, and for the patient. It streamlines the process for everyone. I also really love the Zimmer Biomet implants; I wouldn’t use them if I didn’t. They have an incredible track record and they perform very well for patient outcomes. The fact that Zimmer Biomet has their strong history clinically, but also is a true partner that understands the challenges and limitations of operating in a freestanding ASC, they ensure you’re prepared for not just for your cases, but for any potential issues you may have along the way. That makes all the difference."
A Limited Window of Opportunity
As we wrapped up our conversation, we asked Dr. Frisch what advice he may have for someone who is on the fence about whether to pursue performing their cases in an ASC.
"It’s clear there is a shift to the outpatient environment. I’ve seen a lot of people who were initially resistant and are just now getting into the game a little bit later than some of their peers. Just like with any opportunity where there is a shift in the market and how we deliver care, there are opportunities that exist for a certain window, but then those things become the standard and that window closes. So for people who are in the hospital setting, it’s a good idea to consider the ASC," Dr. Frisch said.
To learn more about Zimmer Biomet’s ASC Solutions portfolio and how it can help you meet your unique ASC goals, visit ZimmerBiomet.com.
To learn more about the ROSA Robotics System and how it can fit into your ASC, please visit ZimmerBiomet.com