Delivery of Care

Living in an accountable world: orthopedic group puts focus on patients

Ortho Rhode Island brings together four independent orthopedic group practices to develop a new business model to deliver specialty health care

Photo by Richard Asinof

Dr. Michael Bradley, president and CEO of Ortho Rhode Island, left, and Mary Ellen Ashe, the executive director of Ortho Rhode Island, at their Wakefield offices.

By Richard Asinof
Posted 9/19/16
Ortho Rhode Island is pioneering a new business model for health care delivery by specialists in Rhode Island, with the goal of putting the needs of the patient first.
Will other specialist practices follow the path that Ortho Rhode Island has created, redefining the landscape in the emerging accountable care world? Are there ways that community health centers can develop new partnerships with Ortho Rhode Island around the managed Medicaid population? Will Ortho Rhode Island consider expanding its footprint and develop a clinical facility that looks at the treatment of pain management? How will wearable devices change the flow of information between patients and providers, particularly around rehab from surgery?
In increasing fashion, as the demographics around aging seniors continue to increase, the prevalence of knee, shoulder and hip replacements continues to expand. Is there a way to help design innovative living environments for the elderly that make it easier for them to navigate the world with rehabilitation resulting from joint replacements? Are their innovative insurance contracts with Medicare that can be created to establish financial support for such redesigned living spaces, based on improved health outcomes and reduced costs?

WAKEFIELD – The story of how Ortho Rhode Island came to be is one that is often typical of how the innovation ecosystem works best: five colleagues from Rhode Island met up at an orthopedic conference. All worked for competing specialist practices, yet they were also friends and respected colleagues, having trained together at the Warren Alpert Medical School at Brown University.

Over a cup of coffee and sketched out on napkins, the new group orthopedics practice was born, asking and answering the question: what if the new group was designed to “think like a patient” and start redesigning the delivery of orthopedic care from the patients’ perceptions of their experiences?

The result was the launch of Ortho Rhode Island in May of 2015, now with 17 locations and more than 55 care providers throughout Rhode Island and Southern New England.

The mission of Ortho Rhode Island is described as the “quadruple aim”: better care, better health care, lower cost, and a fourth element – fun.

The founding members are Blackstone Orthopedics & Sports Medicine, Foundry Orthopedics & Sports Medicine, and South County Orthopedics. Together, they have become the largest and most comprehensive orthopedic practices in Rhode Island. West Bay Orthopaedics & Neurosurgery is slated to join Ortho Rhode Island later this year.

Ortho Rhode Island also has plans to add a new spine center of excellence, beginning in October, having recruited a neurosurgeon to lead the new center.

The medical group’s areas of expertise include: hand, joint, pain management, shoulder, spine, sports medicine, joint reconstruction, primary care sports medicine and podiatry. Ortho Rhode Island also offers physical and occupational therapy, athletic training, MRI and ultrasound imaging, and durable medical equipment. The group also has its own fitness center.

Ortho Rhode Island recently signed a new agreement with UnitedHealthcare of New England, with a focus on value-based care. It has inked similar agreements with both Blue Cross & Blue Shield of Rhode Island and Neighborhood Health Plan of Rhode Island.

The new agreement places an emphasis on patient engagement and information sharing, particularly for those patients choosing elective surgery. Some 140,000 people currently enrolled in UnitedHealthcare’s employer-sponsored health plans are eligible to benefit from this new collaborative agreement, according to a recent news release.

As Ortho Rhode Island moves forward toward its third year of operation, the financial returns so far have been somewhat of a wash, according to Dr. Michael Bradley, president and CEO of Ortho Rhode Island.

Bradley told ConvergenceRI: “I will be completely transparent; it’s been a little bit of a wash.” More than just creating economies of scale, Bradley explained, the focus has been on coming together and doing things that could not be done when the members of Ortho Rhode Island were individual groups.

“What we are doing, looking at the process from a corporate standpoint, is we are investing our savings back into growing the group and into providing services to patients,” he said.

Here is the ConvergenceRI interview with Bradley and with Ortho Rhode Island’s executive director, Mary Ellen Ashe, as they talked about how they have created a new kind of specialty group practice for orthopedics in Rhode Island – and a new business model for how to deliver health care.

ConvergenceRI: Do you see Ortho Rhode Island as being on the cusp of how health care is being redefined, how medicine is being practiced, and how health care delivery is changing for specialists? Are you carving out a better niche?
BRADLEY:
We were frustrated by our current system [of health care delivery]. You can probably tell that there have been some frustrations in [the practice of] medicine over the last five to 10 years, in multiple, different areas.

Everybody was fairly unhappy, and that means, most importantly, the patients, [as well as] the providers, the physicians, the nurses and the physician assistants. It really wasn’t working for the payers as well.

We thought, if there was a way for us to come together, recognizing that it couldn’t just work if you brought disparate groups together, you had to have somewhat like-minded people working together, we could create a new way of looking at the delivery of orthopedic and muscular-skeletal health care.

ConvergenceRI: Does your group include DOs as well as MDs?
BRADLEY:
Yes, we do.

ConvergenceRI: And neurosurgeons as much as orthopedic surgeons?
BRADLEY:
Yes.

We’ve developed a model that is very patient focused. But if you look at the things that people really want, it varies. There are some patients for which it’s incredibly important for them to see the physicians every time. We try to meet their need.

Some people think it’s really not important to see the physicians every time; [they prefer to see] mid-level providers such as physician assistants to get information or to get an injection.

We’re really trying to give people what they’re asking for – and need.

We’re certainly able to do that better now than we could a couple of years ago.

ConvergenceRI: How are the finances working out? You’ve created a brave new model for health care delivery. Have you been able to cut your own operating expenses, to a certain extent, and at the same time, attract a continued flow of patients?
BRADLEY:
I will be completely transparent. It’s been a little bit of a wash, because of the amount of resources that we’ve needed [to invest] as we’ve come together.

If we just came together, and did what you suggested, just use our economies of scale…

ConvergenceRI: I was not suggesting that, I was asking that…
BRADLEY:
It’s a good question. What we really needed to do was to come together and do things that we could not do when we were [operating as] individual groups.

Rather than just saving, what we’re doing, looking at it from a corporate standpoint, we are investing our savings back into growing the practice and providing serves to patients.

ConvergenceRI: It seems to me, what you’re doing is forcing the other players – the hospitals and the payers – to deal with you on a more equal basis. Is that correct?
BRADLEY:
Yes.

ConvergenceRI: In terms of the hospitals, because you work with so many different hospitals, [including Miriam Hospital, Rhode Island Hospital, Sturdy Memorial, Landmark Medical Center, Memorial Hospital of Rhode Island, Southern New England Surgery Center, Kent Hospital, South County Hospital and Newport Hospital], you are asking them to look at you a bit differently. Is that accurate?
BRADLEY:
That’s a fair assessment. Not so much differently, but we have to prove that we when we came together, there truly is a value benefit. We can’t just come together, put a new name on, and expect that everybody to open doors for us.

So, there are some changes that we needed to make. A lot of them we’ve put together, a little bit of a laundry list. Most of those are very patient-focused, either on satisfaction or access, the important things that makes patients become the focus [of care].

ConvergenceRI: How does that fit into the efforts to develop accountable care organizations, or accountable entities, focused on population health? Do you see a need to define yourself in that way?
BRADLEY:
As far as population health and ACOs, these [entities] are coordinating multiple levels of care.

As specialists, we want to participate with these organization, to provide the best orthopedic care possible, but I don’t think you’re going to see us go into the weeds.

ConvergenceRI: In essence, you seem to have created a new kind of species in the world of health care delivery?
BRADLEY:
Yes. We want to make ourselves available as much as possible to ACOs. Several of these organizations were involved [in helping us as the specialty arm, if your will], to develop protocols and standards of care.

There are many different reasons why the cost of health continues to go up. But, I think, everybody agreeing on when treatment is necessary and justified [is a positive step].

That used to be the way that payers would check in with you around utilization, with utilization reviews. Now, I think we’re self-policing some of those things.

ConvergenceRI: The payers are the experts on defining risk and calculating risk. Moving forward, groups and hospitals and accountable entities are being asked to share in how those risks are calculated and assessed. Did you seek out the insurance companies, or did they come to you, in regard to the new value-based agreements. Is it like going out a first date and you may decide to see more of each other, or are you looking for more of a long-term relationship?
ASHE:
[laughing] A little bit of both. But we went to them. We decided internally, we established what we wanted to do: we wanted to create value-based contracts, we wanted to find ways to partner with the payers, so we basically opened the dialogue to find out: what was it that we could do together; what could we offer them; and how could they support us.

That’s how we opened the dialogue.

ConvergenceRI: Has the change to Ortho Rhode Island made you a happier person in your practice of medicine?
BRADLEY:
That’s an interesting question; I don’t know.

ASHE: Maybe a busier person.

BRADLEY: I will tell you that 10 or 20 years ago, if this kind of thing had happened, it would have been about people negotiating for more fee-for-service contracts, and higher percentages.

We understand, at this point in time, we want to do the best job, and certainly to get paid for what we do. We also know, that it would mean, in the next era, to create savings, in some way, shape or form.

That’s probably the key to practicing medicine right now, asking: is there a waste in the system that we can help to identify? [Recognizing that everybody would define waste differently.]

And with Ortho Rhode Island and the new contracts, we’ve tried to create that [awareness] in some ways.

In our fee-for-service contracts, we negotiated them very favorably in the sense that we put everybody in a situation so that they can continue operating the way they are.

And, with most of the contracts, it will allow use to show how we are going to differentiate ourselves from other practices.

ASHE: Every single one of the contracts has brought value, number one to the patients, to the group, and to the payers.

ConvergenceRI: Has the new group organization created a need around the flow of health information? What kind of health IT system are you using? Is it Epic? Or Athena?
BRADLEY:
Good questions. We are kind of downstream in the episodes of care. For instance, for knee pain, the patient is often seen first by the primary care provider. It may go then to another provider, maybe a rheumatologist, maybe someone in sports medicine.

Orthopedics may become involved if and when these people are considering surgical intervention.

We all have electronic health records; we all have the capacity to exchange information between ourselves. And, with larger groups such as ACOs, we are creating communications links that can allow our information to transmit directly to primary care physicians.

ASHE: For us today, for our circle of influence within our group, we have practice management [software], through which we can send out our claims. And, we are working with the ACOs, like Integra, building a better process sharing information. It is not a perfect system yet.

ConvergenceRI: Not every orthopedic surgeon likes to engage with patients. How is Ortho Rhode Island overcoming that kind of reluctance?
ASHE:
When we had our strategic retreat a year ago, patient engagement was what our board said they wanted as the number-one priority in 2016.

What we decided to do, which may be a common practice in primary care offices, but it is not that common in most specialty practices, is we implemented a patient survey.

It’s all-electronic. We survey every patient who comes through the group’s doors, every day.

You can respond by email, text message or voicemail.

We have about a 30 percent response rate. The survey asks about the physician experience, the staff experience, and the experience with the facilities.

It gives us a lot of feedback, and we get feedback every single day.

The survey allows us to compare ourselves to orthopedic groups nationwide, so we always know where we stand. And, the physicians get the feedback as well.

Patients have the ability to leave us a message, and tell us exactly what they think, good and bad.

Friday is [what’s known as] Kudos Friday; we share all the good news on Friday.

We’re proud of it; we get a lot of it, especially [directed toward] the staff.

Another opportunity for patient engagement we’ve found is with patients undergoing elective joint surgery. A lot of patients want to go home; they don’t want to go to a rehab center.

We have the opportunity to engage with them, when that’s appropriate, before surgery, and to understand, from a holistic perspective, not just the clinical, what their needs are, to understand more about their home environment and their social network, and social supports at home.

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