The list price for a knee replacement back in 2016 was around $50,000, but administrators at Gundersen Health System's hospital in La Crosse, Wis., couldn't tell you what it cost them to perform the surgery. Not even an estimate. The actual cost astounded them: $10,550, including the surgeon's and anesthesiologist's fees, according to an efficiency expert, who for 18 months recorded every minute of every activity and took note of every implant, supply and medication, according to an account in last month's Wall Street Journal. In addition to discovering that they were marking up knee replacements nearly 500%, Gundersen was also able to pinpoint waste and cut inefficiencies, eventually saving 18% on the cost of joint replacement surgeries.

We asked Lisa J. Wied, MBA, vice president of clinical operations at the Gundersen Health System, to share some of her cost-savings ideas with our readers. Nothing exotic or earth-shattering, just the bread-and-butter basics of surgical economics.

• Standardize implants. Gundersen's orthopods were using a variety of implants, so they worked to narrow the choices in order to qualify for a reduced rate through a buying group. "When new surgeons come on board," says Ms. Wied, "we tell them that we want them to use these standards, even if they hadn't before. There's been no resistance."
• Examine your supply costs item by item. Gundersen's supply costs were pretty low to begin with, but there was one outlier: cement costs. They were using antibiotic cement, which costs more than antibiotic-free cement. The total joint surgeons weren't married to antibiotic cement, so Ms. Wied asked the purchasing department to find an antibiotic-free cement. "We now add the antibiotic ourselves," says Ms. Wied, "and that reduced our cost greatly."
• Do you really need to catheterize? Thanks to a push by the surgical nurses, Gundersen no longer inserts catheters into total joint arthroplasty (TJA) patients. After reviewing research showing TJAs don't need catheters post-operatively, nurses did a small study at the hospital to test that finding. When they confirmed for themselves what researchers had found, the nurses brought presented their findings to our surgeons, who agreed. "That saves us $30 per case in insertion time and supply costs," says Ms. Wied, "and did away with costs related to catheter-induced infections."
• Decrease length of stay. Over a 3-year period, we decreased length of stay for TKAs by almost a full day (0.8 day). Instead of asking a patient if he's picked his short-term care facility, caregivers excitedly tell patients that they can soon go home if they're well enough. Changing the patient's mindset and setting the expectation of a speedy discharge empowers the patient, says Ms. Wied. Gundersen also trained its physical therapists to get patients up and walking as soon as possible.

What good is a fast discharge if you have to readmit the patient? Gundersen offers patients and caregivers day-of-discharge classes to help patients recover well at home. The classes focus on keeping up with assigned exercise routines, watching fluid intake and eating the right foods.

"TJA patients who take control of their care drastically reduce their risks for readmission and complications related to infection or dehydration," says Ms. Wied

Playbook for success



The team at Excelsior Orthopedics in Amherst, N.Y., one of the leading same-day total joint programs in the country, has developed a "playbook" for success. The keys include:

• Clinical protocols. Total joints have many moving parts where profits can go to die. Spell out everything, from pre-op orders and pre-op testing to post-op pain management and post-op labs. Then there are credentialing requirements and anesthesia (adductor block and general, for example) techniques to follow. Detail your perioperative and pain management protocols. Know what implants and supplies you're using and keep your preference cards current. There's more once you discharge the patient : prescriptions, durable medical equipment (DME) orders, discharge instructions, rehabilitation protocols, data and outcomes. Perform a program quality review every 6 months, says Excelsior.
• Patient selection criteria. There's no specific age criteria, but Excelsior has a long list of guidelines for accepting patients, starting with BMI <40, minimal past medical history with few if any co-morbidities, well-controlled sleep apnea and opioid na??ve. There should be no history of cardio-thoracic or diabetic problems, pulmonary embolism or deep vein thrombosis, blood thinners, rheumatoid arthritis, MRSA or gastric bypass. Then there are the invariables to consider, including patient motivation, family support and the resiliency of the patient.