Published 4/1/2016
Karl M. Koenig, MD, MS; Aakash Keswani, BS; Kevin J. Bozic, MD, MBA

The Role of Integrated Practice Units in the Treatment of Musculoskeletal Conditions

In today's changing healthcare climate, new terminology around value-based care is emerging. Value-based payment has quickly moved to the forefront of the discussion in response to goals set by the Centers for Medicare & Medicaid Services (CMS), which aim to transition the majority of payments away from traditional fee-for-service (FFS).

Value-based payments include bundles and mandated alternative payment models such as the Comprehensive Care for Joint Replacement (CJR) program. However, given that the value equation is defined, from the patient's perspective, as outcomes achieved per healthcare dollar spent to achieve those outcomes, a framework is needed that enables providers to address both the numerator (outcomes) and the denominator (costs).

As every surgeon knows, some interventions are very expensive but still yield positive value in improved function, decreased pain, and a better quality of life. Physicians work at the crossroads of cost and benefit and are uniquely positioned to identify the care that provides the most value to their patients.

Introducing the IPU
With this goal in mind, those wishing to provide value in health care require a framework in which outcomes can be measured while simultaneously calculating costs and resource utilization. This, in a nutshell, is the concept of an integrated practice unit (IPU).

The current medical organizational structure is based on anatomic regions of the body and specialization in certain disease processes. However, this "silo-ed" landscape has created walls between providers who treat similar conditions. Patients are often referred back and forth between different specialties before a diagnosis is reached and then may be bounced around again in pursuit of appropriate treatment (Fig. 1).

Patients with a chronic illness such as cystic fibrosis or ankylosing spondylitis may need to see several different specialists, who may or may not communicate effectively with one another. These patients do not have a clear "captain of the ship" in a situation where their primary disease state affects every medical decision. For them, the model of integrated, multidisciplinary care is probably the only effective strategy for managing their illness.

Consider the possibility that care delivery could be reorganized around medical conditions as they are perceived by patients. If a patient has knee pain, that is the condition. That pain may be due to a meniscal tear, gout, osteoarthritis, or something rarer, such as fibromyalgia or rheumatoid arthritis. Currently, a different specialist would treat each one of those diagnoses, and the patient could easily see two or three providers before the appropriate diagnosis and treatment is rendered.

An IPU dedicated to "joint pain" would bring together all of the providers who treat that condition into one team and under one roof. By working together and communicating in real time about this patient, the team is able to address the knee pain, whether the cause is related to injury, physiologic changes, or ineffective coping mechanisms.

In this scenario, orthopaedic surgeons, rheumatologists, physiatrists, physical therapists, dietitians, and behavior modification specialists would work together in the same clinical setting. Each would practice at the top of his or her license, in a system that measures outcomes and resource utilization for every patient. The team would educate, engage, and manage patients across the full cycle of care. With colocation of providers and appropriate data analysis, the opportunities for cross-disciplinary learning and improvement are endless. Continuous quality improvement will drive better value for patients, and the most successful IPUs will attract the most patients.

It sounds great, right? But one can give a list of a hundred reasons why it won't work. How will the patients flow? How can the cost of surgeons seeing patients who don't need surgery be justified? How will costs be assigned to the IPU and physicians reimbursed for high-quality care? However, a careful look reveals that most of the obstacles to implementing IPUs are related to the FFS reimbursement structure and the systems of care that have evolved in response to it.

Not a new idea
The idea of a multidisciplinary, integrated care model for the management of musculoskeletal disease is not a new one. It has evolved over the years and several prototypes have been trialed, many of them successfully. Although the literature in this area is not extensive, several examples have been published.

Folbert and colleagues have reported their experience with a multidisciplinary geriatric fracture service that included a geriatrician, a surgeon, nurses, and a specialized unit within the hospital and outpatient follow-up clinic. When comparing similar patient populations treated before and after this service was instituted (2007–2008 versus 2009–2010), they found significant reductions in 30-day readmissions (12 percent vs. 1 percent, P < 0.001), urinary tract infections (16 percent vs. 2 percent, P = 0.024), and length of stay (LOS) (1 day shorter).

Della Rocca and colleagues had similar findings in a 3-year retrospective, controlled cohort. Implementation of a multidisciplinary team care pathway for geriatric hip fracture patients resulted in decreased intensive care unit (ICU) admissions (48 percent vs. 23 percent, P = 0.009), ICU LOS (8.1 days vs. 1.8 days, P = 0.024), overall LOS (9.9 days vs. 7.1 days, P = 0.021), and mean hospital charges ($52,000 vs. $38,000, P = 0.02).

Another condition that benefits from an integrated, multidisciplinary approach is low back pain. The Naval Medical Center in Portsmouth, Va., has done extensive work in this area. Campello and colleagues reported the results of a small, single-blinded, randomized controlled trial of active-duty personnel seeking care for nonspecific low back pain. In this pilot study, patients were assigned to either a multidisciplinary spine program (spine physician, physical therapist, and psychologist) or usual care. Patients who received multidisciplinary care reported significantly lower perceived disability after 4 weeks (Oswestry Disablity Index 10.7 vs. 21.0, P = 0.01).

The same research group then went on to compare its model to another large military hospital over 3 years and found that the relative risk of disability was significantly lower for the group treated by the multidisciplinary team (0.53, P < 0.001 in 2007; 0.58, P < 0.001 in 2008; and 0.34, P < 0.001 in 2009).

In 2013, the CHANGE PAIN Advisory Board—leading pain specialists from the United States and Europe—developed a multidisciplinary team framework for the management of chronic pain. This framework includes the primary care physician, a pain specialist, a psychologist, a physical therapist, and a nurse practitioner, organized into syndrome-oriented centers such as headache and low back pain.

In the center, consultations involve two or more specialists and scheduled huddles enable the team to discuss patient needs and assign patients to "ad hoc" services. This framework led to the establishment of nine multidisciplinary centers for chronic pain in Belgium. The success of these centers in improving patient-reported pain scores and satisfaction has led to expansion, with 36 multidisciplinary teams now in operation.

The power of multidisciplinary care
These pioneering groups have shown the power of multidisciplinary teams to improve patient outcomes while simultaneously reducing the cost of care, even in the FFS system. When providers can communicate directly, integrate care plans, and address diseases holistically, the patient benefits tremendously. Still, the fundamental change that has to occur is within the incentive model.

Rather than a reimbursement structure that pays for interventions on a piecework basis, the healthcare delivery system must be rewarded for delivering value to the patient. In some circumstances, such as with a healthy, middle-aged adult with debilitating arthritis of the hip that is adversely affecting quality of life, a low-risk total hip arthroplasty is the obvious high-value choice. However, in a patient with high surgical risk and very low functional demands, choosing not to perform surgery may actually provide more value to the patient.

The IPU framework promotes care that is consistent with the patient's health status, preferences, and goals while measuring the value achieved for that patient. CMS has signaled its plans to transition the majority of payments to providers to a value-based model over the next few years. The reporting of patient-reported outcomes before and after treatment in the CJR model is a concrete step in this direction. Major commercial insurers are following suit, and electronic health record vendors are embracing the need for interoperability to enable these functions.

As physicians, reorganizing ourselves into condition-based delivery models that focus on providing integrated, patient-centered, and appropriate care is our path forward. It's all about the patients and providing value to them. If we keep that in mind, everything else will fall into place.

Karl M. Koenig, MD, MS; Aakash Keswani, BS; and Kevin J. Bozic, MD, MBA, are members of the Department of Surgery and Perioperative Care, Dell Medical School, Austin, Texas.


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