Figure C. Bilateral symmetric joint space loss, erosions and periarticular osteopenia of the knee joints consistent with rheumatoid arthritis.
“Ms. K. is in her 50s, otherwise healthy. She has had severe, untreated, erosive rheumatoid arthritis for over 25 years. She is wheelchair bound due to knee pain and contracture but her strength is preserved. Radiographic images are available for your review (see Figure C). I have never seen deformities of this degree and am not sure if surgery is even an option. What do you think?”
He emailed me back within five minutes:
“I’m your man. Complex joints are my specialty. Send her my way.”
The patient was scheduled to see him the following week.
Six weeks later, Ms. K. underwent bilateral total knee arthroplasty. As arthroplasty cases go, this one was challenging. Due to her disease and inactivity, she had 45º flexion contractures and severe disuse osteopenia. Simultaneous bilateral surgery was required because a patient cannot walk with one straight leg and the other at 45º. However, we worked with her on prehabilitation and prepared her home environment ahead of surgery with our team of physical therapists and social workers to ensure she was set up for success.
To improve the delivery of musculoskeletal care, we had to go back to the drawing board & build a system around the conditions we are treating from the perspective of the patient.
Karl and I remained in close communication both pre- and postoperatively. Preoperatively, methotrexate was continued as per the 2017 ACR/American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Antirheumatic Medication in Patients with Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty.1 Corticosteroids and biologic therapies were deferred until after surgical recovery to minimize the risk of infection or poor wound healing. Shortly post-op, Karl sent me a video of Ms. K. in the rehabilitation gym. She was doing leg presses with near-complete extension of both her knees. A few months later, she walked into my clinic for her follow-up appointment.
The Goal
Patients, payers, providers and policymakers have expressed a need for novel care delivery models designed around patient-centered value and are actively pursuing payment structures to encourage this approach in musculoskeletal care. Why? Because the treatment of musculoskeletal conditions represents a very large portion of the total healthcare spending in the U.S. In fact, the report of the U.S. Bone and Joint Initiative in 2018 showed that adults reported to have a chronic musculoskeletal condition accounted for an estimated $332 billion in healthcare spending from 2012–2014.2
Unfortunately, when considered as a whole, musculoskeletal care is delivered by an enormously fragmented system—primary care providers, urgent care facilities, emergency departments, chiropractors, podiatrists, physical therapists, rheumatologists and orthopedic surgeons, just to name a few. All of them are working in their own separate silos with their own specific toolboxes, disparate success metrics, and absolutely no incentive to communicate with one another. In reality, they are usually competing among themselves in some form. It is no wonder that patients get bounced around, over-imaged and overmedicated. Their overall health is rarely addressed. The system is simply not built to do that particular job.
When analyzed with respect to value (defined as health benefits that accrue to patients per healthcare dollar spent), most current models of practice fall short due to: 1) an inability to measure outcomes that truly matter to patients, 2) limited transparency around the clinical and financial outcomes that are measured, and 3) a lack of care coordination across providers involved in the patient’s musculoskeletal care cycle.3
To improve the delivery of musculoskeletal care, we had to go back to the drawing board and build a system around the conditions we are treating from the perspective of the patient. Multidisciplinary teams with co-location and built-in coordination through a shared incentive structure and measurement platform can and do vastly decrease the waste in the system. This is the basic concept of an Integrated Practice Unit (IPU) and is the cornerstone of a new paradigm in care delivery. When multiple related IPUs are coalesced into institutes—like the Musculoskeletal Institute at UT Health Austin—the silos break down and coordination of care is directly enhanced across conditions.