Orthopedic surgeons are the carpenters of surgery, measuring twice and cutting once as they burr through bone and hammer implants into place. They're doers, not talkers. Instead of discussing how to improve joint procedures, they make it happen on a daily basis by buying into techniques and technologies that push the boundaries of cutting-edge care. Consider all the ways orthopods are teaming up with facility leaders to shape the future of orthopedics and show what's possible in outpatient surgical care.

• Optimized outcomes. Almost any orthopedic surgery, even the most challenging joint replacement, can be done in an outpatient facility as long as you mitigate risks and post-op complications, and manage pain control, PONV and blood loss. In many ways, orthopedics is leading the Enhanced Recovery After Surgery (ERAS) movement with surgeons and outpatient facilities teaming up to manage every aspect of patient care from the moment cases are scheduled straight through to successful recoveries.

We're placing a greater emphasis on spending time with patients in the months before procedures in order to prepare their minds and bodies for the rigors of surgery, and making sure they're ready both physically and mentally for same-day discharge. Advances in regional anesthesia and multimodal pain control are easing the discomfort of notoriously painful procedures with fewer opioids, presenting a blueprint for opioid-sparing protocols and practices.

• Value-based care. Under the bundled payment reimbursement model, insurers pay a single payment that covers an entire episode of care, which begins the day patients schedule surgery and ends at 90 days post-op. Surgeons and facilities must manage every aspect of patient care and take on the financial and clinical risk of doing so, but also stand to profit more than they would under the traditional fee-for-service payment model if they control costs and deliver excellent outcomes. The risk-sharing model incentivizes surgeons and facilities to deliver value-based care, and continues to control the costs of performing joint replacements without compromising quality.
• Market consolidation. In what's representative of a larger healthcare trend, we're seeing a consolidation of orthopedic practices — nationwide, there are 100 groups with 50 or more physicians and 8 groups with 100 or more surgeons — and growing numbers of orthopedic surgery centers being folded into hospital systems.

That trend could help drive down the cost of orthopedic care; larger physician groups and facility partnerships can curb case costs by negotiating volume-based pricing for implants and supplies. I'm also envisioning the possibility of surgery centers partnering with large physician groups to capitalize on the self-insured market by striking deals with major firms to offer their employees access to affordable, quality surgical care.

• Less invasive techniques. Endoscopic orthopedic surgery continues to advance, letting surgeons perform major procedures through smaller incisions. That's particularly evident in spine. Surgeons can perform muscle-sparing endoscopic decompression fracture surgery through a series of stab wounds instead of a traditional midline incision.

In joint replacement surgery, smaller prosthetics and bone- and tissue-sparing techniques have dramatically improved outcomes and how well patients recover, leading to more procedures being performed in the outpatient setting. For example, the anterior approach to the hip socket minimizes tissue damage, allowing for faster, less painful recoveries.

Robotics and image-guidance have made joint replacements more reproducible and accurate, but that doesn't necessarily translate into better outcomes. Still, patients are seeking out surgeons who operate with robotics and increasing numbers of facilities are investing in the technology, so it could alter the landscape of the specialty.

• Regenerative medicine. Platelet-rich plasma and stem cell treatments are slowing the degenerative effects of rheumatoid arthritis, and helping patients avoid hip and knee replacements. Although the treatments have not yet been proven to effectively eliminate the need for joint surgery, surgeons who specialize in regenerative medicine are generating good revenues. There might be a future role in the specialty for outpatient facilities, which should consider establishing a formal pain management and regenerative practice to position themselves for what could evolve into a profitable service line.
• Expanding case volumes. Total joint replacements continue to be one of outpatient surgery's hottest specialties. CMS has removed knee replacement from its inpatient-only list, but still won't pay for procedures performed on Medicare beneficiaries in surgery centers (hip and shoulder replacements remain on the inpatient-only list). We'll know if CMS will pay for knee replacements performed in ASCs next year when Medicare's 2019 final payment rule is released in November. I'm not overly hopeful. My best guess is that CMS will finally reimburse for knees done in ASCs beginning in 2021.

There's speculation about how many Medicare beneficiaries who are in a surgeon's current stable of patients would be candidates to have their joints replaced in an outpatient OR. Some experts believe about 25% would qualify, but I think that's a high estimate. Regardless of how many individuals older than 65 years prove to be suitable candidates for outpatient joint replacement, the number of cases performed in surgery centers will inevitably increase when CMS finally green-lights the procedures. Facilities with established programs in place, including relationships with upstream and downstream providers who help to optimize pre- and post-op care, will be positioned to capitalize on the expected growth in case volume.

The incentive to advance outpatient orthopedics is no longer based solely on performing safe, efficient and effective surgery. It's about delivering value-based, patient-centered care and reducing the expense of achieving excellent outcomes. Orthopedic leaders have for years been putting into practice the concepts that will shape the future of health care, and will continue to lead the way through clinical advances, risk-sharing reimbursement practices and patient care improvements. OSM