Richard Iorio, M.D., Brigham and Women’s Chief of Total Joints, Discusses “Reopening”

by Elizabeth Hofheinz, M.P.H., M.Ed.

Looking for signposts as you make your way through the jungle of reopening elective surgeries? Thanks to a team of orthopedic researchers from Albany Medical Center, Beth Israel Lahey Health, and Brigham and Women’s Hospital, there is now published information on how an economic recovery for the orthopedic field might best be undertaken. Their work, “Orthopaedic Economic Recovery Following the COVID-19 Pandemic: Resuming Elective Orthopaedic Surgery and Total Joint Arthroplasty,” appears in the April 18, 2020 edition of The Journal of Arthroplasty.

Co-author Richard Iorio, M.D. is Chief of the Adult Reconstruction and Total Joint Arthroplasty Service, Vice Chairman of Clinical Effectiveness, and the Richard D. Scott, MD Distinguished Chair in Orthopaedic Surgery at Brigham and Women’s Hospital (BWH) in Boston.

Dr. Iorio: “In an effort to provide guidance as we resume elective procedures, my colleagues and I have attempted to lay out a plan that will help facilities that provide musculoskeletal care survive economically. As such, we have presented 6 Economic Pillars for the resumption of sustainable elective total joint arthroplasty.”

I. Determine Patient Demand for Elective Orthopaedic Surgery Following the Pandemic

In the spirit of assess, then plan, Dr. Iorio states, “Like so many other moving parts of this pandemic, patient demand is a huge unknown. One month ago, all our patients wanted to have surgery in June; now that we are in May, however, they are hesitating. Naturally, they are thinking, ‘I don’t know where I will be living next month, if I have enough to feed my family…and I haven’t received a stimulus check.’”

“Our suggestion is that orthopedic practices approach patients whose surgeries were canceled when Covid hit and ask them if they would like to reschedule immediately, cancel, or wait 3-6 months. In 2008-2009 we had a recession with ‘only’ a 10% unemployment rate. This translated into 30% fewer joint replacements done the following year. What will happen when there is 30% unemployment? No jobs, no insurance or high deductibles…those with Medicare too scared to go to a hospital. Confusion.”

“The pent-up demand that everyone is anticipating will likely not be significant because people are scared or don’t have the money for surgery. And the regional variations are enormous, often varying by county. Mayo Clinic is on track to lose $3 billion, while Partners HealthCare—which runs the Brigham and Mass General—is the largest employer in the state and will also be greatly impacted financially.”

II. Medical Optimization in a COVID-19 World with Evidence-Based Practices

“With screening tests that are only 70-80% accurate, we have results that are difficult to act on,” states Dr. Iorio. “And formulating strict protocols is impossible because no one knows if antibodies confer any immunity. So if a patient is not tested within 24-48 hours of surgery it’s not helpful. If everyone in the OR is wearing N95 masks and taking the proper intubation precautions, then that’s the best we can do for the foreseeable future.”

“Deciding whether everyone has to wear PPE depends on the COVID prevalence density and on the robustness of your PPE supply. Then you have to decide how sick someone must be in order to get surgery. If a patient is very sick and injured, then that is an easy decision: life over limb and limb over function.”

“Then you have some people making the case that playing tennis is urgent. Things are different in California vs New York because the East Coast has seen the worst of it. But older people who are sick should not have surgery. If someone is healthy and can get into a Covid-free environment, then that is ideal. Frankly, most of us are in a position where we have to formulate plans based on local conditions.”

III. Early Discharge and Outpatient Total Joint Arthroplasty

The focus here? “Get patients out of the hospital quickly and minimize in person touches postoperatively,” says Dr. Iorio. “Use a dissolvable suture line, do virtual followups, etc. Assuming appropriate patient selection and screening has been done preoperatively, you must do whatever it takes to get patients out of the hospital environment.”

“And for those individuals who cannot be discharged in a timely manner, it is prudent to send them to a regional facility that has seen only minimal Covid.”

But what of the expense?

“Reimbursement penalties related to site of service and the 2 midnight rule are an issue when it comes to Medicare beneficiaries, and these should be eliminated given the circumstances. Reimbursement issues can also bog down the discharge process, thus potentially endangering patient well-being.”

IV. Technology and Innovation Investment

One of the few bright spots in all of this has been the emergence of telehealth at the front and center of patient care. Dr. Iorio: “At this point, we have been given the green light to use technologies that are not necessarily HIPPA-compliant. Going forward, however, we will likely be required to only use those that comply with HIPPA. A substantial amount of funding will be required to plan and implement telemedicine platforms, with traditional platforms starting around $42,000 and some with per-physician fees starting around $800 a month.”

Pointing to a concern on the minds of many these days, Dr. Iorio says, “If no vaccine is developed, then what will hospitals and clinics look like? You will not have 40 people in the waiting room, for one thing. People will be screened in advance and, just like at a restaurant, they will wait outside/in their cars and be called at intervals. The pace will be very slow. And just having flimsy curtains in recovery rooms won’t cut it. Patients will be staggered to every other bed and everyone on a floor will have a private room.”

V. Renegotiate Contracts with Vendors

Hyperfocused on saving cost, hospitals will have to reevaluate and renegotiate their existing contracts, says Dr. Iorio. “More than ever, it will be time for belt tightening. Given that implant cost drives inpatient costs in total joint surgery, hospitals will need to sit down with vendors and redo contracts. And forget the robots…everyone is going back to basics. Hospital capital spending will greatly decrease.”

VI. Government Programs

Pointing to his home facility, Dr. Iorio notes, “We are running at 50-60% capacity as opposed to our typical 90-95% capacity. While we are too large for government programs, orthopedic practices with fewer than 500 employees can benefit from the SBA via the CARES Act. These loans can be as large as $10 million and may be forgivable if utilized for payroll and employee retention.”

Highlighting the upheaval that has taken hold, Dr. Iorio says that the chief of orthopedics at MGH has been redeployed as a scribe in the pulmonary department. But he has not given up hope for some semblance of normal.

“Once we get everyone making enough PPE and its use becomes routine…once anesthesia becomes more accustomed to doing intubations in this environment, well…it will be much like the inception of the HIV crisis where we are taking universal precautions at all times.”

So when will that be? That too, is yet another unknown.