Patient Education Boosts Revenue, Quality for Joint Replacements

February 21, 2018 - Offering interactive patient education pre- and post-total joint replacement surgery is key to improving patient outcomes and generating new revenue, a multi-specialty hospital system in the Twin Cities area recently found.

An estimated 7 million Americans are living with a hip or knee replacement, making total joint replacements one of the most common inpatient procedures.

Despite the high prevalence of these procedures, care quality and costs for total hip and knee replacements significantly vary. Average Medicare spending on surgery, hospitalization, and recovery can be anywhere between $16,500 to $33,000, CMS reports.

Rates of complications can also be up to three times higher at some facilities than others, resulting in greater chances that a patient may be readmitted to the hospital.

Hospitals may be performing multiple total joint replacements a day, but providers are struggling to lower the costs of the procedures while improving patient outcomes.

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HealthEast in Minnesota is working against that using a patient education platform to engage total joint replacement candidates before and after surgery to avoid costly complications and potentially boost its revenue by almost $4 million by increasing its capacity to perform high-value surgeries.

Ensuring high-value joint replacement surgeries will also maximize revenue under bundled payment models designed to target joint replacement episode spending and outcomes.

The journey to improving total joint replacement surgery costs and outcomes started when Todd Smith, MD, HealthEast’s Chief Medical Information Officer and Executive Medical Director of Health Informatics at the newly merged Fairview Health Services, noticed the benefits of a patient education platform from UbiCare used in the health system’s obstetrics population.

The platform identified pregnant patients through the EHR system and sent the women e-mails on a weekly basis. E-mails would contain educational information on pregnancy and the baby’s development, as well as reminders to make appointments with their providers.

The patient education initiative lasted up to two years after delivery as long as patients chose not to opt-out of the program.

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The popular outpatient patient education system presented an opportunity for the inpatient side with total joint replacement patients.

“I thought that this would be another great population because we’re always trying to decrease length of stay and improve outcomes and decrease readmissions,” Smith recently told RevCycleIntelligence.com.

Smith worked with UbiCare to install a similar patient education platform for total joint replacement patients using custom content developed by the health system. In addition to pregnant women, the platform now also automatically signs up joint replacement surgery patients.

“They get six e-mails before they have surgery,” he said. “The great thing about this is that we own the content, so we can edit it. We can put in what we want. We can pick out what we want. And we can really tailor the education content to what we want.”

Smith works with the health system’s orthopedic counsel to develop and manage content, which allows HealthEast to target performance measures specific to its patient population and quality performance.

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“As to the content, a lot of it is truly geared towards certain marks that we want to hit,” he stated. “For example, we are looking at same-day surgery cancel. That’s a revenue cycle driver. If you have a patient who comes in and there was something wrong with their pre-op exam or they’re a diabetic and it’s not controlled and that wasn’t picked up in their pre-op, that’s an OR that’s sitting empty.”

Allowing an operation room to sit idle can cost anywhere between $200 to $400 per minute. “That’s a huge revenue loss,” Smith explained.

“If we can impact same-day surgery cancels, we can impact that revenue potential,” he continued. “When you look at what makes people do same-day surgery cancels, they’re things like infection and uncontrolled diabetes. It could be that they forgot, then had a sandwich at 2:00 in the morning. So, our education is tailored to that. It might be, ‘Make sure you go see your doctor ten days before our pre-op exam. Make sure if you’re diabetic, you do this test. Make sure that you don’t eat anything after 10:00 at night if you’re the first surgery.’”

HealthEast also used the patient education platform to target another common cause of same-day surgery cancels at the health system.

“We also had looked retrospectively at last year’s data and found anemia was a big one,” he said. “We had these people coming in, doing hemoglobin tests, and they would be anemic. They’d cancel a surgery on the same day.”

“What can we do to prevent that,” he asked. “We tailored some education to that. You can do a proactive message saying, ‘This is what mostly causes people to cancel on the same day of surgery.’”

Additionally, HealthEast aims to ensure a high-value total joint replacement episode even after the surgery. The health system sends patients messages after their surgery to improve post-acute care spending and outcomes.

“There are three or four messages after the surgery for six months,” Smith elaborated. “If they end up in the emergency room, guess what, they’re going to get admitted. And most of those patients don’t need to be admitted. So, we tailor that education around how to prevent readmissions. Our message says, ‘If you think you have a problem, first call your primary care doctor,’ or ‘If you start seeing redness around your wound, give your doctor a call and don’t automatically go to the ER.’”

Preventing avoidable hospital readmissions is key to avoiding value-based penalties from payers under initiatives like Medicare’s Hospital Readmissions Reduction Program or bundled payment models that measure readmission rates as part of incentive payment determinations.

While providers were eager to deliver information to patients to ensure a high-value total joint replacement episode, HealthEast found that patients were receptive to receiving more information. Nearly 70 percent of patients enrolled in the first iteration of the patient education initiative opened at least one-half of the emails sent.

With patients engaging with the messages on top of orthopedic quality improvement projects, hospital readmissions fell to three percent even though the health system boasted a 3.8 percent hospital readmission rate prior to implementing the program, Smith reported.

Patients also heeded the advice given in the educational messages, preparing themselves to recover in a low-cost, familiar environment – their home. Now, only 6.2 percent of total joint replacement patients enrolled in the platform go to a skilled nursing facility after surgery instead of home versus almost one-quarter of all total joint replacement patients prior to platform implementation.

“We try to build in the education to change that mentality that has been built up over the last 20 years that says if you are over X age, well you’re just going to go to a nursing home to recover from this,” he remarked. “That’s not true anymore. We’re trying to battle that mentality, and we address some of that in the pre-op education.”

Patient education added an important layer to HealthEast’s orthopedic quality improvement initiatives, allowing patients to be a more active participant in increasing care value. Alongside patient navigator and quality improvement initiatives, the educational messages could help HealthEast to boost its revenue.

Preliminary data from UbiCare showed that interactive patient education may be able to reduce length of stay for total joint replacements by 15.6 percent.

A 15 percent reduction in length of stay would allow HealthEast to take on 268 new total joint replacement patients each year based on their case volume, resulting in almost $3.9 million in new potential revenue.

While generating additional revenue is a major bonus for HealthEast, Smith touted the health system’s quality improvements with total joint replacement episodes. As the health system prioritizes high-quality, affordable surgeries, HealthEast’s revenue potential should grow as productivity improves and value-based reimbursement rewards high-value care.

“You have to squeeze every dollar out you can,” Smith concluded. “But do it with the patient in mind and with quality and safety as the number one priority.”