People who got joint replacements only a few years ago might be surprised by what happens now after patients get their new hips and knees.
Now that new payment schemes encourage surgeons and hospitals to pay more attention to the cost and effectiveness of the care patients get when they leave the hospital, postsurgical rehab has become a target for cuts.
Where - and how - joint-replacement patients get physical therapy is changing rapidly. Far fewer are going to inpatient facilities for rehab. A growing number are skipping home care and going straight to outpatient therapy. Some hip and knee patients are getting no professional physical therapy at all.
"We're completely transforming how physical therapy is done," said Antonia Chen, a Rothman Institute surgeon.
Michael Greco is happily testing one way to save money.
He went home the day after a Rothman surgeon at AtlantiCare Regional Medical Center in Galloway installed his new knee. Then, instead of having a physical therapist come to his house in Egg Harbor City, Greco, 55, chose to get outpatient therapy and do exercises by himself at home. He has the assistance of Force Therapeutics, a computer program that demonstrates proper form and tracks his compliance and pain level. It even links to an app in his phone that measures how many steps he takes each day.
While costlier home therapy is the norm, Greco thought he would benefit more from specialized equipment at the therapist's office. And Force looked easy.
"I have the smartphone and I use all the technology," Greco said while demonstrating exercises he does three times a day. "I didn't think twice about it." A month into recovery, he said that "everything is going well."
There are a lot of joint-replacement patients like Greco, so changes in costs can have a big impact. About 74,000 people in Pennsylvania and New Jersey had total knee or hip replacements in 2013. Virtua health system officials estimated that a typical stay in a nursing home after surgery costs $12,000 to $15,000. An average home-care episode costs $3,500. A Rothman spokesman said a course of outpatient physical therapy costs about $720.
In 2011, 42 percent of Rothman knee-replacement patients and 25 percent of those with new hips went to an inpatient facility after surgery. During the first 10 months of this year, that percentage fell to 15 for knees and 11 for hips. Those who still get inpatient rehab tend to be old and frail, have other medical problems, or have insufficient support at home. Meanwhile, the percentage of patients who went straight home with only outpatient physical therapy rose from 13 to 62 for knee replacements and from 10 to 74 for hips.
A recent Rothman study found that hip-replacement patients did no better with physical therapy than with just "walking around" and home exercises, Chen said.
She still orders outpatient therapy for most of her knee-replacement patients, but fellow Rothman surgeon Carl Deirmengian has over the last few years begun sending most of his knee-replacement patients home with no physical therapy. If their knees are still stiff when he sees them two weeks later, he orders therapy then. About 10 percent need it.
Deirmengian contends that modern surgical methods and pain control allow for much quicker recovery. Patients are walking and climbing stairs almost immediately. They don't need to aggravate their painful knees with lots of extra exercises.
"You've got the next 10 years to strengthen the knee," he said. "Do you really want to start the therapy the day after surgery, when it hurts the most?"
He says his patients are doing better now. "I have never in my career seen the knees look so good," he said.
Though less pronounced, similar trends are occurring in other large orthopedic practices in the region.
"I think we've been paying a lot more attention to trying to do things more efficiently and more effectively," said Charles Nelson, chief of Penn Medicine's joint replacement division. Since 2013, the percentage of patients who go straight home has risen from about 20 to 50.
Nelson thinks that patients who go right to outpatient therapy, still a small number at Penn, benefit from getting out of the house. "It's better mentally for patients and it's better physically," he said.
Jeanne Connelly, vice president operations for 3B Orthopaedic Institute at Aria Health, said the number of patients sent straight home after joint replacement has increased by 10 percent a year for the last two years. Fifty-six percent now go home. Connelly said they're safer and more comfortable there.
At Virtua, about 90 percent of joint-replacement patients now go straight home or to outpatient PT. Most patients don't see a nurse at home.
Abington-Jefferson Health sends someone to evaluate patients and their homes before surgery. Everyone gets a nurse navigator, who coordinates care for 90 days, said June Weise, administrative director for the Orthopaedic and Spine Institute. In a year, the percentage of patients who go to a nursing home after joint replacement has dropped from 52 to 37.
She said there has been some pushback from patients who feel entitled to more attention. "My mother has paid into Medicare," one family member said. "She deserves that service."
Orthopedic leaders insist the PT trends are about high-quality care and, sometimes, patient desire to avoid co-pays. But they also say that what happens after the hospital stay, which accounts for more than a third of a procedure's cost, is getting more scrutiny as they accept more "bundled" payments.
These contracts pay hospitals for an episode of care that begins before surgery and ends 30 to 90 days after. Providers share in savings if they can bring expenses down. They lose money if care is inefficient, and they are penalized if patients have to return to the hospital.
Abington's Weise said that, before bundling, hospitals had no idea what happened to patients after they were discharged.
Weise said the 90-day readmission rate fell from 16 percent during 2009 to 2012 to 7 percent during the eight months after bundling started this year.
Some rehab facilities and therapists are raising alarms about the change in how PT is delivered.
Stuart H. Shapiro, CEO of the Pennsylvania Health Care Association, a nursing home trade group, worries that the "dramatic shift" over the last six months is occurring without adequate research.
"There's good data to show that good rehab gets people functioning faster and better," he said.
Bill Boissonnault, executive vice president of professional affairs for the American Physical Therapy Association, said studies show that patients are more likely to do exercises correctly under a therapist's supervision.
Paul Bach, executive vice president at Kennett Square-based Genesis HealthCare, said the company's orthopedic rehab business has declined at nursing homes, but Genesis sees opportunity in working with hospitals that are bundling.
Genesis also sees a gap in home-based care: people who are not sick enough to qualify for home care, but have transportation problems. Eighteen months ago, it began taking the equivalent of outpatient physical therapy to people's homes. "We are taking the clinic to them," Bach said.
Bronwyn Spira, the physical therapist who started Force Therapeutics in 2010, originally saw videos as a way to improve on the stick-figure pictures of exercises that patients often are given. Then she realized that a physical therapy Web portal had bigger potential in an environment where everyone was focused on "value." Here was a chance to let "patients take on some accountability and recover on their own."
In 2013, the year Force began working with Rothman, there were 400 patients on the platform. She expects 8,000 this year. (Rothman Institute is now an investor.)
Spira expressed little sympathy for fellow physical therapists who might be losing business. "I think that health care is changing and . . . every stakeholder in health care needs to look closely at the value they're delivering," she said.