The Shift in Care Delivery - As the healthcare delivery system evolves, hospitals may no longer be the first stop for patients seeking orthopaedic care. This is evidenced by the growing trend of surgeons moving to the outpatient setting, as patients seek less invasive procedures. Orthopaedic urgent care centers have also emerged as a viable alternative, due to their ability to address price concerns in the industry by reducing time and overhead costs for both providers and patients. Attendees gain more insight into this shift, and learn how it will affect demands on manufacturers from a product design and delivery standpoint.

2. Alejandro Badia, MD, FACS
CEO/CMO, OrthoNOW LLC - Orthopedic Urgent Care Franchise
Hand & upper limb surgeon
Badia Hand to Shoulder Center

3.  Consumer oriented
 Outpatient services expanding
 Aging population
 Bureaucracy/regulations
paradoxically increasing
 Automation/depersonalization
 Less invasive (orthobiologics/
gene therapies…)
Healthcare changing drastically…

5.  Expensive
 Inefficient
 Redundant
 Unpleasant
 Unfriendly
Perfect Storm of Healthcare

7.  Ambulatory Surgery Centers
 Diagnostic Centers
 Retail Medicine
 Urgent Care Centers
 Medication Dispensing
 Telemedicine and Mobile Apps
Cost effective shifts….

8.  National survey of Ambulatory Surgery in US (2006)
 35 million amb surgeries, of which 20 million in hospital systems
 Time spent: 146 minutes vs 97 minutes for free standing ASCs
 GI scope, cataracts and spinal injections top 3 procedures
 Approx. 6000 free standing ASCs . Driven by MDs as first one opened in
early 70s by 2 physicians in Phoenix.
 Medicare pays an ASC 55% of the fee paid to hospital outpt dept for
same surgery.This number has continued to worsen….
 Technological advances facilitate ability to do cases on outpt basis
 Medicare and many carriers do NOT cover cost of implants at an ASC
Ambulatory Surgery Centers

10. Specialty urgent care centers have similar goals
as generalized entities
Improved pt access
Decreased cost
Quality similar or superior to traditional ERs
Specialty UC/ retail medicine can partner to
avoid hospital referrals
Emphasis on multi-partner ambulatory system
Diagnostics
ASCs
Rehab facilities
Emerging Healthcare Entity

12.  General urgent care centers
 Primary care walk in facilities
 Retail walk-in clinics (MinuteClinic)
 Pediatric urgent care
 Cardiac/vascular urgent care
 Ob/Gyn or Women’s urgent care ctrs
 Orthopedic urgent care
Urgent care/walk in Healthcare

13.  Most musculoskeletal injuries are seen
late in the game
 Unless injury is open and/or severe, many
orthopedic/sports injuries are shuffled between
hospital, primary physician and urgent care
centers long before the appropriate specialist
is called in.
 This is time consuming, expensive and
frustrating (mostly for patient and providers)
The issue

15.  Long waits
 Expensive (copays or full bill if uninsured)
 Correct diagnosis may be missed
 General urgent cares may not be adept at certain
musculoskeletal injuries i.e. “Jammed finger concept”
 Inefficient
 Trainer/parent STILL has to take athlete to orthopedist for
f/u or definitive treatment in most cases
 Delay can adversely affect outcome
and athletic performance
 Current initial step can be modified/altered
Problem with current protocol

16.  Obtain timely emergency care
 Maximize clinical result in order to regain premorbid level
of function for athlete
 Minimize costs and inefficiencies
 Maximize communication to referral source
(coach/trainer/supervisor/carrier)
 All facets of treatment under one roof (outpatient)
 Avoid litigation issues
Orthopedic injuries: dilemmas

17.  Involve the specialist early, preferably the subspecialist.
 Allow that provider to order the appropriate tests NECESSARY to
formulate treatment plan
Concept of a center is optimal for efficient and quality care
• Accepts emergency visit from trainers, coaches, parents, ER and
general “urgent care”
• On-site radiographs, MRI, lab capabilities and creating an alliance with operating
rooms is the ideal scenario. Therapy is beneficial as well so clinician can closely
follow the recovery process and intervene early communicating with ATC
The Solution

19.  Cost-effective Healthcare needed
 People frustrated with hospitals
 Orthopedics has huge direct/indirect impact
to society and costs
 Increasing age of society
 Major shift towards fitness
- Crossfit
-Triathlons
- Gimmick Races
- X-games mentality

20. Business community
recognizes cost
benefits of prompt ,
high quality
Orthopedic care….

21.  Physicians often receive blame for high costs/inefficiencies
 Patients don’t understand R&D and regulatory challenges
affecting medical device/pharma industries
 Pts continue to feel that employers/insurers will
“take care of them”
 Frustrations misdirected. (lack of education
to public/consumer)
Public perception issues

25.  Change ingrained culture of healthcare delivery
 Acceptance by public/referral sources
 Adoption of insurance (networks…..)
“AUTHORIZATION”
Disruptive Innovations in Healthcare

34. Impingement commonly termed “bursitis”
Common in general population as well as sports world.
Nuances to each group, however.
Rotator cuff tears and labral tears usually need repair and
respond poorly to therapy /NSAIDs
Identifying this early saves time/money and can improve outcome
Clinical Example: Shoulder pain

35. Physical exam, radiographs and MRI: 1 visit!
Dispense meds, begin Rehab or ARP neurotherapy,
alter activity
Surgical problem: Arthroscopic procedure can scheduled first
visit depending on clinical and imaging findings
Streamline evaluation process

36. Terrible and nonspecific misnomer
May be one of many different pathologies
PIP collateral ligament tear / dislocation
Phalangeal fracture (articular?)
Jersey finger
Mallet finger
Boutonniere
Volar plate injury
Clinical Example: “Jammed Finger”

37. Salvage procedure for delayed
referral from urgent care center

39. Severely crushed
Middle phalanx base
At PIP joint of finger

40. Hamate graft
From wrist in place
With two screws

42. Hamate bone from
wrist

45. rom Patient’s personal Facebook page

46. Alternative protocol for care???

47. Clavicle fx in surgeon/avid cyclist

48. Pt fell in mountain bike trail.
He considered ER visit but his brother, another
surgeon, recommended orthopedic
urgent care, OrthoNOW
Seen within minutes, on a weekend, with
subsequent x-ray images transmittedTO the
appropriate subspecialist orthopedic surgeon,
who happened to be lecturing abroad.
Pt. directly scheduled for procedure in adjacent
outpt surgery center upon surgeon’s return.
Total time of assessment/decision
making: 70 minutes
Next step: surgical plating at same
facility: NO hospital
Seen at
OrthoNOW Doral
Saturday AM

52. Patient missed no work
after clavicle ORIF
The surgeon shown here 72 hours after
procedure!! Working…..
He attended OrthoNOW triathlon symposium
90 minutes (Fit Triathlete) after leaving OR#1
at surgery center at doral !! Sling and dressing
in place…
Major procedures, including arthroplasty
surgery (joint replacement) can be done safely
in outpatient environment with good
anesthesia/nursing team with less
complications (nosocomial infections),
hassle AND cost.

53. Fast, efficient, and
Precise orthopedic care
With Less Stress, LessWait
And less Cost

54.  Orthopedic industry depends on clinician not end-user
for product adoption
 Involvement in healthcare delivery affects product/implant utilization
 Patients increasingly becoming “Healthcare Consumers”
not passive recipients
 Hospital/Insurance domination beginning to shift
-Obamacare paradoxically leading to increase cost
-High deductibles takes insurance out of equation.
-Avoidance of expensive healthcare delivery (i.e. hospitals)
Ortho Industry/ Clinical synergies

56.  Educate patients and referral sources
in network copays often similar to straight cash pay
 Encourage specialty care (paradoxically the most cost effective)
 Strengthen industry/clinician synergies
(despite “Sunshine laws”)
 Patients are consumers and free market
system should prevail
Quality of care should influence cost and drive progress/innovation
Health insurance should be seen as “Catastrophic Care Insurance”
Cost savings would fund “safety net” for those patients in need
How to influence/benefit from shifts?