Should You Be in the Business of Fixing Fractures?

Orthopedics

By: Kendal Gapinski

Published: 8/1/2019

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Outpatient trauma care is a cost-effective and patient-satisfying option for repairing minor breaks.


Increasing numbers of patients with broken ankles, cracked fingers and busted wrists have the injuries splinted in emergency rooms before undergoing fracture repair surgery in outpatient ORs. "There are a few reasons why," says Anthony A. Romeo, MD, chief of orthopedics at the Rothman Orthopaedic Institute in New York, N.Y. "First and foremost, there is a high level of patient satisfaction. The other reason is value. We can provide the same or better outcomes in an ambulatory setting at a fraction of the cost."

Research backs up that claim. A recent study including 61 patients who had ankle fractures — among the most common traumatic orthopedic injuries — surgically repaired at a tertiary referral hospital and 81 patients who received treatment in the hospital's surgery center says outpatient ankle fracture repairs cost 31.6% less than inpatient cases (osmag.net/B8SgcU).

"The main factors contributing to the higher costs were the labor and facility expenses," says study co-author Clayton C. Bettin, MD, an orthopedic surgeon at Campbell Clinic Orthopaedics in Memphis, Tenn. "We also found there were no differences in rates of reoperation, readmission or return visits to the ER for patients treated on an inpatient or outpatient basis."

Another study comparing the costs of inpatient and outpatient fracture repairs says routine hospitalizations for ankle repair surgery result in about $367 million in facility reimbursements each year. In 2012, according to the study, inpatient ankle surgeries resulted in nearly $8 million in facility reimbursements, compared with a little more than $4 million in payments to outpatient facilities for treatment of the same injuries. The study notes that a greater understanding of the economic implications of inpatient ankle fracture surgery could lead to more procedures being performed on an outpatient basis.

Is it time to add fracture repair to your case mix? In this era of value-based surgical care, the choice appears obvious.

Getting started
SURGEON PREFERENCE Deciding to perform fracture surgery in ambulatory facilities instead of acute care hospitals has the potential to save the healthcare system hundreds of millions of dollars.

"Fractures of the finger, wrist, ankle, forearm, elbow or humerus that don't affect nerves or the vascular system can be treated acutely with a splint, and scheduled electively in an outpatient facility," says Dr. Romeo.

If your facility already performs elective orthopedic and sports injury cases, there isn't a lot of equipment you need to buy for trauma care, says Dr. Romeo.

  • C-arm. This is typically the biggest capital equipment item you may need to purchase. A full-size C-arm, along with the required safety equipment, health department approvals and maintenance fees, can cost around $100,000. Additionally, Dr. Romeo notes that more surgeons are using 3D CT navigation systems to plan procedures, with the images broadcast on flat screen monitors in the OR. Manufacturers of 3D C-arms claim their technology provides enhanced images of anatomy to help surgeons better determine where to place pins and plates. The technology can tack on an extra $50,000 to $100,000 to the cost of a regular C-arm.
  • Ultrasound. If your anesthesia providers aren't already performing ultrasound-guided nerve blocks, you'll likely need to purchase an ultrasound unit. Though ultrasound machines can cost up to $100,000, manufacturers of new compact units say their systems offer the same image quality with a smaller footprint and price tag. Also make sure you have a quality anesthesia team in place that can place the blocks appropriately and quickly, says Dr. Bettin.
  • Instruments. On the supply side, surgeons will want access to a set of mini, small and large fragment instrument and implant sets, which are necessary to pin or plate a variety of fractures.
  • Implants. If your surgeons need a specialty implant, you can often work out agreements with vendors to get what they need on short notice.

"Surgeons working on a complex fracture of the lateral clavicle would probably need to call a vendor 24 hours beforehand, so they can deliver devices needed for the case," says Dr. Romeo. "Fortunately, trauma care has been spectacularly supported by the orthopedic medical implant industry, so you can call company representatives who provide trauma sets, and they will often be at your facility within hours."

The difference between performing profitable procedures and operating in the red often comes down to the cost of the implants. Although Dr. Bettin's study found that implant costs for outpatient fracture cases tend to be lower than those for inpatient procedures, he says surgeons who are unaware of the costs can easily double or triple the expense of an individual case.

"There are a lot of ways to fix fractures with implants, and you can often achieve the same quality of repair with different implants that can range in price," he says.

For example, Dr. Bettin notes that surgeons can use non-locking plate implants starting at around $500 for repairing a fibula ankle fracture. "But locking-plate implants in which screws engage with the plate — which tend to be used in more complicated cases — can run between $2,000 and $4,000."

Medicare and Medicaid typically do not reimburse for implants, according to Dr. Bettin, who says private insurers are more likely to cover the cost of an implant by working it into the overall reimbursement for the case, though the amount varies depending on the contract.

Patients are in the OR by 7 a.m. and on their way home by 11 a.m.
— Anthony A. Romeo, MD

"Some insurers will pay only the cost of the implant, some will include an extra 1% to 3% for processing charges and some will reimburse a higher overall rate for the procedure to help offset the implant costs," explains Dr. Bettin. "You need to have good communication with your payers, a solid precertification process and make sure the cost of the implant is covered before performing procedures."

Surgeons need to be aware of the cost of implants and the reimbursement contracts with third-party payers, adds Dr. Romeo. He says, "When the cost of one implant is remarkably different than another, and they both provide the same outcomes, the cost of the more expensive device has to be negotiated lower, or the surgeon should switch to the less expensive but equally effective device."

Seamless transition

When patients arrive for surgery, Dr. Bettin says they receive a nerve block in pre-op to dull sensation in the injured extremity. The surgeon fixes the fracture, and patients recover in PACU before being visited by a physical therapist, who makes sure patients who suffered lower extremity injuries can safely use crutches. Patients are then discharged home with appropriate blood clot prophylaxis and receive a phone call from the facility's nurses the next day to make sure recovery is going well.

Aside from the ache of the injury, it's a painless experience for patients.

"They're often discharged within 2 hours of leaving the operating room," says Dr. Romeo. "If it's a hand or wrist fracture, we have them in the center by 6 a.m., in the OR by 7, the case completed by 8:30 and send them on their way home by 11."

Though it might seem like the unpredictability of fracture repair cases would be chaotic to manage, Dr. Romeo says performing the same types of cases — repairs of fractured wrists, fingers, forearms, ankles and feet — makes it possible to create care plans that lead to efficient, successful surgery.

Facility administrators and clinical leaders need to come together to create a clinical care pathway for trauma cases, suggests Dr. Romeo. "The care provided in the outpatient environment is very predictable," he says. "When you do trauma cases routinely, you know exactly how to prepare patients for surgery, the necessary level of anesthesia, how much nursing care you need, special equipment to have on hand and how to recover patients after surgery. All that can be organized and planned out before trauma patients come to the surgery center." OSM

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