Twin Cities Orthopedics—Excel Orthopedic Surgery and Recovery Program

Researching options for quality patient care is a daunting task; attempting to understand the cost of that care is even more difficult.

Medical bills are infamous for their proliferation and indecipherability, and medical procedures are almost never presented with a transparent fee. These frustrations are amplified by the significant variation in procedure cost from one region of the country to another and, even within the same city, from one hospital system to another.

Surgeons at Twin Cities Orthopedics (TCO) have taken a remarkable step toward demystifying healthcare costs and elevating care quality by asking a single provocative question: What would it cost for TCO to offer a bundled total knee replacement, with state-of-the-art subspecialty care, for a single, all-inclusive fee presented on one bill that patients can understand?

Their answer, after months of research and negotiation, surprised them and is delighting their knee replacement patients. For an all-inclusive fee of $21,000, presented on a single itemized bill, the TCO Excel Orthopedic Surgery and Recovery Program provides patients with a plan that includes individualized patient education; gold-standard surgical procedures; proven, state-of-the-art devices; comprehensive medications; medical facility recovery suites; specialty orthopedic nursing care; and physical therapy through patient recovery. TCO’s fee is less than half the cost of a comparable knee replacement at other facilities in Minnesota and 20 to 30 percent less than the insurance reimbursement averages for a knee replacement in the Twin Cities.

Owen O’Neill, MD, physician in the Excel Program, and Troy Simonson, CEO of TCO, sat down with MD News to describe their process for creating the Excel Program and their vision for the role of single-fee, quality-care programs like theirs in health care.

“Originally, we focused on providing better care that wouldn’t raise costs,” Dr. O’Neill says, “but we found that our approach actually lowered the cost of care by 30 to 35 percent compared to doing a full knee replacement in a hospital system in the metro Twin Cities. Nationwide, the cost gap between our fee and another market’s fees may be as much as 50 to 60 percent because the Twin Cities is one of the lowest, most efficient healthcare environments in the country.

Twin Cities Orthopedics Surgeon
A Twin Cities Orthopedics surgeon performs a total knee replacement on a patient at the Crosstown Surgery Center.

“We designed the Excel Program to address problems we saw in the marketplace,” he continues. “Medical bills are confusing. People have a hard time sorting them out. I’m a physician, and even I find healthcare billing hard to understand. We felt that if we could offer one bundled, understandable bill for an event that covered everything, then the people paying the bills could understand them, whether those people were individual patients or managers at a self-insured company, or at a health plan.”

In their approach to a single-cost knee replacement, TCO believed that if it could control every aspect of the procedure and recovery, they could elevate the quality of patient care and deliver a better patient experience.

“When we send patients to the hospital, we don’t control the nursing care or the operating team or the delivery of recovery care for the patient,” Dr. O’Neill explains. “We felt that if we had everything under our control, with specialty trained orthopedic nurses in the operating room and monitoring patient recovery, our patients would receive better care.”

TCO accomplished its $21,000 knee replacement fee by capturing savings at multiple points through the procedure. It negotiated with gold-standard implant vendors, the anesthesia team and surgeons. It established best-practice protocols to manage patients during the procedure and at the care facility. It worked with the pharmacy to develop a protocol for pain medications and assigned orthopedics-trained nurses to administer medications through the recovery process. The program engages patients and their care advocates from the first appointment through assignment of an Excel Program nurse practitioner, individualized educational seminars, preprocedure therapy programs to improve recovery time and dedicated rehabilitation facilities on the same floor as the recovery suites.

Physical Therapist
A Twin Cities Orthopedics physical therapist guides a patient through his postsurgical therapy session.

A Focus on Patient Satisfaction

The Excel Program is designed to deliver the highest level of medical care with individualized patient attention. When a patient is referred, the patient and his or her caregiver consult with the surgeon and Excel Program nurse practitioner. Afterward, the patient and the caregiver attend a 90-minute educational program during which the Excel Program nurse practitioner and a physical therapist present an individualized overview of the surgical, recovery and therapy processes. During the program, the therapist explains preoperative steps patients can take to strengthen themselves before surgery, which leads to improved recovery.

“I don’t think we’ve done an educational program for more than three patients at a time, and it is usually one or two,” Simonson remarks. “In a large group setting, patients feel awkward about asking questions. Our educational program creates an individualized environment that invites questions. Our patients feel prepared and confident, and this contributes to a better patient experience.”

TCO’s program education and recovery facilities are deliberately designed to encompass the needs of patient caregivers.

“The education of the caregiver is critical,” Simonson says. “We know that by educating and involving our caregivers, we significantly reduce their anxiety. Our recovery suites are designed so that the caregiver can comfortably stay with the patient and participate at every step of rehabilitation. When patients are discharged, we want the caregiver to feel confident that he or she can help the patient navigate stairs and safely go about their day. We help caregivers gain a complete understanding of the process, beginning with our preop teaching and including access to our Excel Program nurse practitioner to answer any questions.”

On the day of surgery, patients review procedure information in a preoperative suite. During surgery, a waiting area and café are available to caregivers. After the procedure, caregivers rejoin the patient in a surgical center recovery room. When the patient has recovered from surgery and is discharged from the surgery center, a nurse accompanies him or her in a medivan to a fourth-floor recovery suite at TCO’s contracted orthopedic recovery center a few blocks from the surgery center.

While other outpatient facilities release patients to a hotel or their homes for postoperative recovery, TCO was committed to designing an infection-controlled recovery environment staffed with trained orthopedic nurses. The bundled fee provides as many as three days in a private recovery suite with kitchen and bathroom facilities, meal service, physical therapy in a therapy center located on the same floor, in-suite accommodation for a caregiver, and 24-hour access for visitors and family. During recovery, the patient’s one-on-one nursing care is handled by specialty registered nurses employed and trained by TCO.

The comprehensive level of medical care included during the patient stay in the recovery suite is designed to maximize patient safety and comfort. The patient is visited by the surgeon and evaluated daily by a medical internist. A physician is on-call 24/7, as needed, during the patient’s stay at the recovery suite.

“We set patient expectations, and we decrease the variability in care,” says Dr. O’Neill. “Patients understand the importance of beginning rehabilitation immediately. Because they are so completely engaged and we are focused on delivering specialized orthopedic care, they typically leave the recovery suite a full day sooner than they’d typically leave the hospital.”

Upon discharge from the recovery suite, the Excel Program includes follow-up checkups and physical therapy for at least 90 days.

“We’ve actually extended physical therapy beyond 90 days for some patients, making therapy essentially unlimited until patients are where they need to be,” Simonson notes. “It’s rare that a patient would need 120 days of therapy, but we try not to limit resources. Some patients might need six therapeutic visits, and others might need 25. There’s nothing predefined. Our program is designed to deliver therapy that is customized to our patients’ needs.”

Eligibility for the TCO Excel Program

Not every patient requiring a knee replacement is a candidate for TCO’s Excel Program. Outpatient procedures are typically restricted to otherwise healthy individuals. The Excel Program criteria exclude patients who are morbidly obese and those who have a history of heart attack or other heart problems.

“Unfortunately, there is also an age restriction because Medicare will not cover procedures that do not include a hospital stay,” Dr. O’Neill adds. “Many Medicare patients who are otherwise great candidates request our program, but we can’t help them based on Medicare’s restrictions.”

Post Surgical Knee Exercise
A Twin Cities Orthopedics physical therapist assists a patient with a postsurgical knee exercise. All physical therapy visits are included as part of the Excel Program’s bundled price.

The Future of TCO’s Excel Program

“Patients recover faster in our program because they are motivated, engaged and well-informed,” says Dr. O’Neill. “Our patient satisfaction scores are off the charts and unquestionably higher than those of hospital patients. We rolled our program out slowly last summer because we felt it important to have all the systems in place and absolutely zero hiccups. Thirty-five patients, including a prominent CEO and a physician, have gone through our program so far, and two of those patients have already scheduled return visits to replace their other knees.”

“No one else in the Twin Cities has bundled all knee replacement costs into a single bill, and we are providing the highest level of postoperative, orthopedic nurse-supervised facility care with an internist available on call,” Simonson says. “The level of care we provide after surgery is critical, and it sets our program apart.”

Although insurance companies have been slow to adapt their claim adjudication processes to the procedural simplicity of TCO’s single-bill approach, Medica and HealthPartners now cover Excel Program procedures, and TCO is beginning to contract directly with self-insured employers.

With the Excel Program for knee replacement established, TCO is broadening the program capabilities to offer single-fee shoulder, hip and ankle replacements. The appeal of a transparent fee for gold-standard care is attracting patients beyond the Twin Cities. In October, TCO admitted its first international client, a Canadian patient in need of a hip replacement. For national and international patients, TCO can conduct preoperative consults, monitor therapy and handle follow-up consultations via Web visits.

“I think we’ll see other practices doing what we are doing,” Simonson predicts. “In today’s healthcare marketplace, patients all have choices about where they go for care. Programs like ours create what I think has been absent in health care forever: a free market. Everyone should know what everything costs, and everyone should have access to a superior quality of care. We are stewards of health care; it is our responsibility to make care for our patients better, more efficient and less expensive.”

“Our patients love the experience we give them,” Dr. O’Neill says. “One patient switched his insurance so we could do his knee replacement. They refer their family and friends to us. They are delighted, and that’s the greatest reward of all.”

Source: MD News November 2013, Twin Cities Edition



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