Episode 31 – November 2021: Next Day Joint Replacement plus ACA Open Enrollment

Julie: This is BACON, brief ACO news from the MaineHealth Accountable Care Organization, a Fricassee Monthly podcast for health care providers. I'm Julie Grosvenor.

Mike: And I'm Mike Clark. Julie and I are practicing physicians and liaisons with the MaineHealth ACO.

Julie: In this episode, we meet two orthopedic surgeons. I love that, that we keep featuring orthopedic surgeons. But two of them. Yeah. Two who have made amazing progress reducing recovery time after joint replacements.

Mike: But first, we learn how providers can help eligible patients enroll in ACA marketplace insurance plans. That's our Meaty Topic for this month, so let's dig right in.

Speaker3: Meaty Topic.

Julie: It's fall and besides pumpkin spice, that means open enrollment for health insurance plans. In recent years, MaineHealth's access to care team has mobilized during this season to enroll eligible patients in the ACA marketplace plans, popularly known as Obamacare.

Mike: Yes, and today we welcome Beau Michaud from Access to Care. He's going to walk us through how practices and providers can help in this effort. Welcome, Beau.

Beau: Thank you both for having me. I'm excited to be here.

Julie: Yeah, we're glad you could come to talk to us. So I guess first things first, when is open enrollment occurring? When?

Beau: Yeah, it's a good question, because there's a lot of open enrollment periods kind of this time of year. So, the open enrollment period for the health insurance marketplace is from November 1st to January 15th of next year. So which is great and something we'll talk about a little bit later on, but that is a longer time frame for us, which is pretty nice. Typically, open enrollment has only been six weeks and we got it extended this year. The federal government extended it another four weeks, so we have a total of 10 weeks to help enroll people in marketplace plans this year. And those folks at the end of December who maybe are making some New Year's resolutions and want to get serious about their health care or health insurance, they have some extra time to be able to do so.

Julie: That's wonderful.

Mike: That's great news. That's great news. So who does this affect? Who's eligible to enroll?

Beau: Absolutely. So to keep it simple, the way that we look at it is in two categories people who in order to be eligible for a marketplace plan, you need to be a U.S. citizen or be a legal resident in the United States. And then you need to not be offered employer health coverage or have Medicare as well. But that that not being offered employer health coverage is really the most important thing that providers can remember when it comes to someone who's eligible, potentially eligible for a marketplace plan.

Julie: So is there anything, in particular, that's new or different this year that we should be aware of?

Beau: Absolutely. So a couple other things, too that are really going to impact positively consumers this year. The first is the American Rescue Plan, and it opened up the open enrollment period, basically the open enrollment period from last February through August, which was great. We helped a lot of people through that. But in addition to it, the benefit was also the financial assistance that people received. So, it basically expanded the amount of people who could receive financial assistance through the marketplace and also the amount of assistance that current enrollees were receiving. So I know that's a lot, but those benefits, both to people who are newly eligible for financial assistance, and then people who can receive deeper financial assistance, that is extending into 2022, which is huge. So, for providers who are helping patients, just being able to recognize and know that in general, most likely people are going to be able to get a little bit more financial assistance and it's an option out there. That's really important. Not that we would expect a provider to know the nitty-gritty or the specifics of who's eligible for what, because so much of it can be a little bit confusing in terms of someone's eligibility based on their income, their household size, their legal status, and so on. But that's where we came in. That's where the Access to Care team comes in. And just having that general framework to be able to share with people that, hey, you're going to be able to get some more, potentially you can get some more assistance on the marketplaces here. That's what we're really excited about. And then lastly, I'll mention is something called the state-based marketplace. So this year, Maine is going into managing their own platform. In years past since the ACA or Obamacare rolled out in 2013, we've been on the federal marketplace, so that's healthcare.gov, which a lot of people are familiar with. This year we're moving to a state-based exchange, so it's coverME.gov, cover Maine .gov. So that coverME.gov is going to be the way that we help patients. And the benefit for the state is that it allows them more autonomy when it comes to their marketing, their outreach, and allows them to put a little bit more of a local flavor to the website and some of the plans that are going to be available on there. That's great. So those are a few of the big things that we're seeing and some changes that we're seeing this year when it comes to open enrollment and what it's going to be really important for, again, providers to know, is just that there is a group out there, there's a team out there that is able to help these folks. We don't expect any provider to know the specifics of the marketplace. But just knowing how someone could potentially be eligible and then send them over to us is going to be great because then we can help them enroll in the plan if they're eligible.

Mike: That's great. So any tips for our listeners as to how they can best connect their patients with ACA enrollment or with the Access to Care program, any tips or takeaways for our audience?

Beau: Absolutely. I think we certainly have, you know, an email address and a phone number that we can share. That's going to be the best way to refer people to the access to care team when it comes to enrolling patients or consumers in a marketplace plan. One thing to keep in mind, too, is that the most important thing is knowing that someone is either a U.S. citizen or a legal resident and that they are not offered health insurance through their employer. If both of those two qualifications are met, I'm not going to say it's guaranteed, but there's a really good chance that we can help someone get financial assistance through the marketplace. In fact, 80% of people who are enrolled in the marketplace have some sort of a subsidy or financial assistance that they get. And Sixty thousand Mainers have a marketplace plan, so it's a good chunk of people who are having and are eligible for it. That's the most important thing for providers. Just following those two steps. From their access to care can be a one-stop-shop, even if someone is not eligible for the marketplace. That doesn't mean it was a bad referral. We can help patients sign up for Maine care. We can answer questions on Medicare, Social Security. There's a lot of different ways that we can help patients, so we kind of look at it as a no wrong door policy that we'll be able to help patients no matter what. So obviously, we're here talking about open enrollment and in the marketplace, but if it doesn't end up working out for a patient there, we'll do our best to provide them with access to insurance as we can. So, in order to best refer patients to us, we have an email address that we use, called getcoverage@mainehealth.org. And I can share all this information as well afterward. And then the phone number for that same group is 662-7930. And if you contact us and one of those two ways, we'll make sure to reach out to the patient and see how we can assess.

Julie: Well, thank you very much, Beau, this is really so helpful, and I think you've made it as easy as you can possibly make it for people to get the information they need. So thank you so much.

Beau: Of course, thank you for having me.

Julie: So for links to ACA open enrollment resources, please visit MaineHealthACO.org/BACON and look for the page for this episode, which is episode number 31.

Speaker3: The sizzle.

Mike: Yes, it's time for the sizzle. Our segment featuring MaineHealth ACO participants doing good things inside or outside of work.

Julie: This month, our producer, Paul Santomenna, talks to Dr. George Babikian and Dr. Adam Rana about their work to shorten recovery times after joint replacement surgery. George and Adam are part of Maine Medical Partners Orthopaedic and sports medicine practice.

Paul: So you've both been deeply involved in creating these next-day joint replacement surgery programs at Maine Medical Partners, so can you just give us the basics? You know, what is next day? What does that mean and what are the advantages to patients? Maybe, George, you can go first.

George: Next day, you know, literally is that traditionally it's been an overnight in the hospital. What it really means to me is instead of saying words like minimally invasive, it means that we're doing a minimally impactful surgery, meaning we can replace your hip and make it very easy for you to go home the next day because the operation is so atraumatic that it doesn't really hinder your function the way hip replacements traditionally get.

Paul: And Adam, talk about the knee replacement work.

Adam: With regards to the knee program, my goal for the past number of years has been to align the knee program in terms of outcomes in terms of, as George highlighted, minimally impactful, as opposed to minimally invasive approach for knee program. And we've worked really collaboratively over the course of the past five years with our anesthesia colleagues for changing the way we administer some of the anesthetics with some of the blocks that we use. We've really engaged the nursing teams and the physical therapy teams for educating our patients in terms of what to expect before, during, and after surgery. And then the surgery itself, we've just really streamlined the procedure so that it is less impactful than where it had been historically. And taking it one step further, I mean, we talk about a next day hip or the next day knee, but we've taken it one step further over the course of the past couple of years to an outpatient hip and an outpatient knee where patients are going home the same day. And that evolution has been a result of a lot of factors. One CMS has taken hip and knee replacement off of the inpatient-only list in 2018 and 2020, and that has changed the sort of paradigm of where patients can go for their hip or their knee replacements. And then, with the COVID pandemic, patients are less likely to want to stay at a hospital. Definitely not tertiary care centers, and we can talk about it down the road. But we've evolved to take our hip and our knee program outside of Maine Medical Center to our Scarborough Surgical Center campus. What we're doing these cases outpatient or next day.

Paul: So, George, can you talk about the quality metrics you've collected and the performance that you've achieved.

George: So we've, you know, through the course of time, we've followed outcomes scores. We're currently use the UCLA activity and prompts. We tracked readmissions both 30 and 90-day ER visits. Complications including infections, fractures, dislocations, and medical complications like pulmonary embolism and GI bleeds in the most objective way we can. And we've recently completed a seven-year review, all hips done at Maine Med from 2013 to 2020, about 63, 6400 hips. All of those results are better way better than national benchmarks and in fact, probably the best results ever reported for a large series like that. Consecutive, non-selected patients. For us, for me, the fact that you can have a length of stay under one day in about 40% of our hips are now going home the day of surgery with a readmission rate that's somewhere around 1% with a national benchmark of 4% and a complication rate way, way, way under 0.4%, that's when you hit it out of the park. We're sending them home before one day with low readmissions, low complications, which demonstrates that it truly is minimally impactful. And we're not sending people home too early. They're ready to go home, and they don't need to come back to the hospital. If you do a very clean operation with minimal soft tissue damage, implants placed securely and solidly in an anatomic position. So you restored anatomy with, well, fixed implant and you've done a minimum of soft tissue damage, the pain is not significant and the return of function is relatively quick.

Adam: Paul, to give us some additional context, where the patients go is huge, so patients are going home. Now, if you look at the orthopedic literature and the experience around the United States, 70% of patients go home, maybe 80% of patients go home at high-performing arthroplasty centers. We have an upwards of 95% percent of patients with 97% percent of our hips were going home last year, and we just broke the 90% threshold for knee patients going home. And that has been, you know, as a result of everything George has mentioned. But people across the board do better. Patients do better at their own home environment with their own bed, their own meals, their own family members. That is the best place to recover, and our data suggests that is true. And by the way, it also significantly reduces the 90-day perioperative cost for taking care of patients. If patients go to rehab facilities that has been shown to be over 40% of the episode of care is for patients going to a rehab. So going home not only is the better place for patients to go, it's better for health care dollars spent. And so it saves a tremendous amount of money for the health system by getting patients home.

Paul: Ok, I think that's a good place to leave it, gentlemen. So thanks very much for your time and congratulations on the success you've had, and here's to further success in the future.

George: We'll keep trying hard.

Julie: Thanks for listening to BACON this month. You can find all our episodes on your podcast app and at our web page MaineHealthACO.org/BACON. And if you have questions, comments, or suggestions, we'd love to hear from you. Please email us at bacon@mainehealth.org. That's bacon@mainehealth.org.

Mike: Bacon is produced by the MaineHealth Accountable Care Organization with help from MaineHealth Educational Services. Thanks for joining us. See you next month!

Julie: See you next month!