Dr. Wael Barsoum: What the Biden Presidency Could Mean for Orthopedics

 This article originally appeared in Becker’s Spine Review on December 4, 2020

As an orthopedic surgeon and veteran healthcare executive, Wael Barsoum, MD, sees the Biden administration taking steps to accelerate population health in orthopedics.

Dr. Barsoum is the former president of Cleveland Clinic Florida and current president and chief transformation officer at Phoenix-based HOPCo, a provider of musculoskeletal value-based outcomes, orthopedic service line and practice management. Here, he discusses his outlook for orthopedics in the coming years and what the Biden presidency could mean for the field.

Question: What effect do you anticipate the Biden presidency will have on orthopedics?

Dr. Wael Barsoum: President-elect (Joe) Biden campaigned heavily on refining and expanding the Affordable Care Act with the addition of a public option, calling it ‘BidenCare.’ If BidenCare is similar to what we saw a decade ago, then far more people will have access to health insurance, and in turn, utilization will likely increase. In the musculoskeletal space, this may mean that many patients who are in need of care, but were uninsured or underinsured, may now have increased access through the expansion of Medicaid or federally subsidized insurance plans.

Proof of this may be shown in a recent study in the Journal of Bone & Joint Surgery  that examined the timeline for hip and knee replacements in over 4,000 new Medicaid enrollees from 2008 to 2015 under the Affordable Care Act. The data showed that the enrollees under the expansion of Medicaid had a far shorter timeline to a joint replacement than the others in the study. For surgeons and hospitals, this means there will likely be a surge in demand for care.

This is coming at a time where CMS continues to refine bundled payment protocols and incentives. Hospitals and surgeons need to have pathways that reduce variations and improve outcomes to deliver high-quality care to these new enrollees, while still managing upside and downside risk. Those prepared with value-based programs will have the best likelihood of success.

Q: What is your outlook on orthopedic care delivery for the next two to three years?

WB: My belief is that changes in [Bundled Payment for Care Improvement Advanced] and other programs being considered by the federal government clearly signal a broader shift toward population health, which will be the catalyst to orthopedic care being increasingly delivered in vertically integrated systems that align physicians, hospitals and payers. The main driver of this will be reducing variability and cost while improving patient outcomes. As physicians and health systems take on more financial risk, the ability to manage the entire continuum of care is imperative. Care will shift to lower-cost sites of service, such as surgery centers, and health systems must have a coordinated strategy to maintain volumes and margins in the hospital setting through more integrated value-based care programs and more intensive and effective inpatient care redesign.

Q: Where do you see the best opportunities for cost savings in orthopedic care delivery?

WB: The best opportunity for cost savings is in choosing the right site of care for patients. Several procedures are coming off the inpatient-only list at the end of 2020. However, that does not mean that all joint replacement or spine cases should be performed in an ASC setting. Using analytics to predict patient outcomes and risk stratification for complications will be essential to choosing whether the case is best performed in a hospital or an ASC setting.

Another opportunity for savings will be the growth of specialty hospitals. Due to their smaller administrative teams, and highly specialized focus, physicians and staff can create process improvements that increase efficiency, turnover and overall outcomes. In multispecialty community and tertiary centers, care redesign to allow margin maintenance in the face of decreasing reimbursement is critical, as is becoming the destination brand for appropriate inpatient cases that allow the backfill of migrating volume.

Q: What are you most excited about and what makes you nervous for the next year?

WB: What excites me is that we are seeing the first steps toward true population health models in orthopedics. This is an opportunity to disrupt the traditional way we deliver healthcare while improving outcomes, aligning stakeholders and decreasing costs.

What makes me nervous is that many healthcare systems are slow to react to change. They may be world-class in delivering traditional healthcare, but there are obvious signals that healthcare delivery is changing in ways that they may not recognize or accept. While many resist change, they should instead be exploring ways of swiftly aligning stakeholders to pivot and improve. My concern is that many of them will be left out in the cold if they do not adapt their models away from fee-for-service and into more value-based models.