Hi, everyone, it's nice to meet you all. As he said, my name is Michael Sheeran. I've been at Rothman Orthopedics for the last 11 years. I've been in health care for 30 years in the Philadelphia market. Prior to that, I was a health care administrator at the University of Penn Health System. When I was asked to share my thoughts on this revolution from inpatient to outpatient, I first wanted to preface all of my comments by acknowledging the incredible work on the clinical side that so many of you all have done to ensure that this transition in care has been done in a thoughtful way, using evidence-based medicine, and to ensure that patient safety, quality, and service has come first. I'm coming at this from a business perspective, but I think it's really important to understand that first and foremost is right patient, right procedure, right facility at the right time. And that has to be the mantra to begin with. So my thoughts on the outpatient, inpatient to outpatient revolution. First of all, I think to call it a revolution is a little bit of, it's a little confusing to me. I think of it more as an evolution. I mean, 20 years ago, we were talking about reducing length of stay, and we were doing PCI only inpatient, and then it went to outpatient. This is just part of the process as far as I'm concerned. So I would, first of all, describe it more as an evolution. Am I hitting, or to, forward, there we go. So I'm looking at this more in terms of this being, to me, this is a patient and a physician choice revolution or evolution. To me, this is a post-operative care path and resource utilization evolution. We're really talking about bringing value, using evidence to bring value to the patient and to the market. Think about site of service for a minute. We brought patients from quaternary and tertiary centers to community hospitals, and then there was this move into specialty hospitals, and now more recently, over the last four, five, six years, there's really been a movement into surgery centers. But if you look at surgery centers, there are surgery centers that are owned by hospitals, and they're referred to as HOPDs, and then there are surgery centers that are owned by physicians, like many of you. Do you know that the cost for a surgery to be done in a surgery center is about 60%, same procedure, same surgeon, same supplies as it is in an HOPD? So really what we're talking about is a shift to really what we'll call the lowest common denominator spot without compromising quality and without compromising care. Boy, I'm really screwing this up. So what are the drivers? Really quickly, obviously it's cost. We're seeing more and more risk being shifted to the patient, and more and more risk being shifted to the surgeon as well. I think it's important that we recognize more and more patients are looking for care to be provided closer to home, and a lot of you as surgeons are being narrow-networked into finding and working in lower-cost facilities. We're also seeing a stronger movement on the part of employers. They're looking for predictable costs. They're not looking for a race to the bottom, but if you're a national company, health cost variation from the East Coast to the West Coast can be tremendous. So everyone is pushing for control. Everyone is pushing for predictability. Oop, did it again. So as some of the implications to this, health systems are consolidating. When Rothman started with Jefferson, it was a two-hospital system. Now I think they're up to 12. So we're seeing large orthopedic groups consolidating, we're seeing health systems consolidate, and certainly we're seeing payers consolidate. With consolidation, payers are getting leverage. Look what Optum is doing under United Healthcare as their umbrella organization. They're buying private practice groups, they're buying subspecialties, and then they're driving patients out of hospitals and into surgery centers. Rothman has always gone into ambulatory surgery centers and specialty hospitals with health system partners. And we do that because we believe not only do the health systems provide leverage, but it really reduces the consternation between the surgeon and the health system when we're talking about moving cases from inpatient to outpatient. Finally, last couple of thoughts. What we're dealing with in the Northeast, I'm sure a lot of you are seeing across the country, what the payers are trying to implement isn't necessarily consistent with what our local legislations support. So if Mike Ciccotti wants to do a total knee replacement in New Jersey, he can do that in our Cherry Hill Surgery Center. The patient could be discharged at seven o'clock at night and go home. In the state of Pennsylvania, we need a certificate of need and a waiver for that procedure to be done. It has nothing to do with the 23-hour 59 rule. It's just the Department of Health rule that you can't do a total joint in the surgery center, regardless of CMS's rule on reducing the inpatient-only list. So state-specific legislation still becomes difficult. When we talk about transparency and price, I also think there needs to be more transparency in quality, more transparency in service. I have seen a deficit in the IT systems with a lot of the surgery center EMRs. I'm concerned about the viability of independent surgery centers with all of the consolidation. And then finally, I'll leave you with this idea of price transparency really being a two-edged sword. On one hand, I love the idea of competition. On the other hand, this race to the bottom starts to scare me and concern me when it comes to how low can we cut and staffing and the materials that we're using. So look, I think we're on a journey. We've been on a journey for 20 years. We will continue to be. And I think it's the right thing to do, but I think we have to be thoughtful in how we do it. Thank you.

Michael Sheeran

healthcare administration

evolution of care

outpatient care

patient safety