questions and I'll break it down. Basically we've covered two topics here, the micro, the micro of operational aspects of getting to an outpatient setting, making that transition more aggressively and more efficiently, and I think as Andrew would say, also more safely, and then Michael covered some macro topics that we can go. So we have a couple questions coming up and if you have, please feel free, I think we're a small enough room, stand up, please identify yourself and where you're from. If not, we can continue to take the questions as they come through, I think we had an initial comment from Dr. Burt, Jack? Just a question, because this was implied in two of the talks, what do you guys in the audience think is the most common reason after total joint to come into the emergency room in the first 72 hours, and I'll give you three choices, hemarthrosis, infection, or anxiety? How many think number one, infection? How many think number two, hemarthrosis? How many think anxiety? And that's the right answer, in this group of 2,500, that was the most common cause, and as you pointed out, and as you pointed out, that's a huge problem you have to optimize preoperatively in these patients, or you're gonna run into a whole lot of patients calling you at 10 or 11 on the first or second post-operative day, just scared to death. I think Jack's alluding to on the, say the $10,000 bundle total joint replacement that ends up in the emergency room for the $3,000 enema. So certainly opioid management, and I guess, Andrew, I'll just have just a quick question on that. How strong is, say, the preoperative education, and where is that education coming from at Vanderbilt? Is that being handled in the orthopedic level, or the anesthesia department? Just operationally, how are you guys managing that? Yeah, that's a great question. So it's handled in all of the above. So at Vanderbilt, we have a preoperative, this mic's off. Anyway. You can speak loud enough. We have a preoperative clinic, and so our high-risk patients are at the preoperative clinic, and we talk about opioid management, and pain control strategies with them. For patients who are with chronic pain that are expected to be difficult pain control patients post-operatively, they'll come to the outpatient pain clinic, and they'll see someone like myself. And then all patients who are likely to be normal pathway as expected pain control, that's all being handled in the outpatient surgery clinics. And Andrew, one question along those. Are you guys currently recommending PO antibiotics within 24 hours for total joint replacements on an ASC setting? Not that I've seen. Jeffrey, I got a question for you. You're in a large group. Orthopedic Illinois have over 50 physicians. Have you taken surgeons out of the outpatient environment and saying that, listen, your mode of practice, your skill set, your patient group does not serve the larger mission of the group better, and you should stay in the hospital? How have you managed those physician-to-physician interactions? Yeah, so I think Jack kind of alluded to some of that. That's probably the most difficult levels of conversation that you have when you get into an ASC setting and it's physician-to-physician management. We have done that. We've done that through limiting or removing access to the ASC based on, and on some level, it was a mutual decision a little bit. It was instigated by us, but once we got into some of the data and why we were doing that, the surgeon did understand. And we've translated that also into current bundle payment arrangements as well. We certainly have physicians that are part of them and not part of them. Other questions, please raise your hand. Eric, I've got a quick question for you. Obviously, I think you and I were both involved in the NOLC lobbying on prior authorization. Where do you think we're going? I mean, do you think we've got, I know the Academy is putting tremendous resource on this one. Yeah, it's not only the Academy, it's also the lobby for the health insurance, the AHIP is in support of it, the AMA and the American Hospital Association. So there's a unique support from the medical community, especially communities that interests typically don't align, which means that we could see some positive movement on the legislation. It's in ways and means right now. It's something that you could potentially see coming out of the floor at the end of the year. But I think if there's any changes in the language, especially since the insurers are paying attention to it, they could water down some of the favorable physician friendly verbiage that's used in the legislation. And so we need to just pay attention and stay engaged and make sure that nothing slips by us. Certainly, I think the most egregious use of pre-authorization blockage is in the Medicare Advantage plans. And I think we're seeing broad based denials. I think you were showing denial rates of up over 50%. And I think that will slowly drift back into the regular commercial market. But we're hoping that legislation will sort of give us a little break on that. Go ahead, Jeff. Question from the audience, I think probably open to every panel member here, that we've seen it with bundled payments, ASC, pricing transparency. How do we avoid? Are your thoughts on avoiding a race to the bottom? Michael, I'll let you jump at that. I'd like to wonder what the Rothman approach is and your Jefferson and Health Partners approaches on transparency. How hard are they working at it? Are we dragging our feet? Or what's your thoughts? The concern for the race to the bottom, I think, is something that we're all feeling. We've decided that we're going to race to what we think is a responsible level in price. We're seeing, again, like I said, we're seeing a lot of centers that are cutting so low that I'm concerned about the viability of those centers over the long period. I believe in transparency. And it's been a process. Because Jack and I, I think we saw things a little differently when it comes to owning a center 100% versus owning a center with a health system. I don't know that there's a right or a wrong answer. But I can tell you when you are joint ventured with a health system, price transparency becomes very, very difficult. Because their fear is if their ownership in an LLC and they publish rates that are much lower than what they're publishing, what they're getting for the hospital, that their rates are going to be at risk. So even though we're proponents of price transparency, it becomes very difficult because every one of our centers has a health system partner. Let me ask a question to the panel as well. Go ahead, Eric. I'm sorry. So I've got a little bit of a unique perspective because I'm in a 10-man group in rural South Georgia. Blue Cross has 70% of the market share in my area. So if they bring a contract to the table and we don't agree with it or don't like it, we really don't have much of an option unless we want our commercial payers to decrease by 70%. So they've monopolized and expanded these markets. So I think size matters when negotiations, when you've got very big groups. And even in a relatively rural marketplace, we've got neighboring groups that we've been in discussions with. But ultimately, I think it's going to be get big or get eaten. And so I think moving forward from the private practice to continue to survive, I think the sizes are going to have to be larger than they are today. I think I'll dovetail that. I think kind of what Michael was saying. And really, that goes to two points. I do think that orthopedic groups have to consolidate by what means, whether it's just a partnership or pure consolidations or whether they use a strategic partner. Because we see that the health system consolidation continues to pursue aggressively. And we're seeing larger and larger amounts of consolidation, certainly in the market that we're in in Chicago. That's an extensive issue. And we can say for clear that health care system consolidation leads to increased price per unit expense. I was at a recent lecture where we had the SVP of health care for Walmart, who covers over a million insured lives. And they believe that same point, that health system consolidation is a negative for them. And they are actually moving to data granulation to such a level that they are going to be providing selective providers inside of even large orthopedic organizations. The data that they're collecting on each of us is just astounding to that point that we're going to say within a practice of 50 doctors, they may select only 10 of orthopedic Illinois doctors amongst that group. So the information flow is getting such that everything we're doing is transparent. I saw a bill. Did you have your hand up? Yes, sir. Is there any data that says that if you're a big group, you're going to get a better contract than a small group? Is Rockland getting that much more money because you guys are managed well than the guy down the street who does the same CVP? No. I would say on the surface, no. But where we have done well. So when we went to the state of New York, we were anonymous. And by the way, we weren't the biggest group, right? Because you're only as big as the docs that you have in that division. So our approach wasn't really to bank on size like we would in Philadelphia and New Jersey. But we came with a value proposition that said, we can lower the cost of care. And here's the playbook to do that. And it's really going to be by site of service selection. So for us to be able to deploy this strategy, we were able to negotiate a premium on our professional fee so that we could carry out that mission. We went into contracts with the commercial payers that agreed to two-year lookbacks on rates if we, in fact, were able to move cases that are being done in hospitals in that area out into the outpatient setting. So it wasn't on size. But I can tell you, we know we did better than the average in New York. And similarly, we just finished our negotiations in Central Florida with Florida Blue. And based on what we've learned in terms of the benchmarks, we've done fairly well. Now, our Florida division by the end of this year will, again, only be about an 18-man group. So it wasn't on size as much as it was on our ability to deploy site of service, lower cost care. And just to tag along to that, too, I can tell you in our market, Blue Cross Blue Shield has an A and a B fee schedule. Doesn't matter how big you are. It's where your tax identification number is located in terms of zip code geography. But there's lots of examples of recent mergers in both the Northeast and the South where they've jumped on better contracts of smaller groups. And those overall much larger groups have seen significant increases, up to 25% in fee schedules. I'm going to take this a different spin. And again, just an association I belong to, we have a lot of conversation with large employer groups. And their belief is that driving unit costs down is bad. They know that there's a level of cost and care where efficiency and effectiveness really bottoms out and you lose all efficiencies. The big decision point now that I'm seeing in large employer groups is really appropriateness of care. They'd rather pay a higher rate with lower utilization or more appropriate utilization that meets standard passage or care pathway management as opposed to just driving unit costs down. They know that the unit cost is a failing entity that really is doomed to the past. So I think that's the things that we're going to see in our associations, this association, AOSSM, ANA, AOS. We've got to make sure that our own association base would develop proper care paths and appropriateness of care. And I think that's the lasting value that we can provide as physicians. I think, well, any last questions? We're getting close to our time of wrapping up. I want to thank our speakers today. I think they all gave us some, like the standard orthopedic lecture, they gave us more questions than answers. But I think they gave us all a lot of help. Thank you very much for attending.

outpatient settings

total joint replacements

preoperative care

opioid management

price transparency