Better Performers: Great care from people who care (Missoula Bone & Joint LLC)

In the bucolic northern Rockies of western Montana, where five valleys and three rivers converge, lies the state’s second-largest city, Missoula. A destination for outdoor enthusiasts and home to the University of Montana, it is also the location of Missoula Bone & Joint LLC.

About Missoula Bone & Joint LLC, Missoula, Mont.

• Better Performer in Operations
• 200 employees across one main clinic and three satellite locations in western Montana
• Founded in 1956 by the first two orthopedic surgeons in Missoula, the group was first known as Missoula Orthopedic Associates and would subsequently become known as Missoula Bone & Joint after nine physicians from Missoula Orthopedic Associates came together in 1999.
• MBJ opened its first outpatient surgery center in 2001 and recently opened a 31,949-square-foot state-of-the-art facility with four surgical suites and private recovery rooms. In addition to offering ankle, foot, hand, hip, knee, shoulder and wrist surgical procedures, the new facility provides total joint replacement procedures and outpatient spine procedures, allowing patients to stay at the clinic for up to 23 hours. 

According to Sami Spencer, FACMPE, CMM, chief executive officer, the practice has around 200 employees, including 115 FTEs at its main clinic in Missoula. There are 14 physicians, including 12 board-certified orthopedic surgeons, 10 physician assistants, 10 physical therapists and one hand therapist. Besides its main clinic, MBJ has three satellite clinics in western Montana.

The majority of patients are 18 to 59 years old (46%) or 60 and older (also 46%), with the remainder (8%) under 18. The payer mix is 42% Medicare, 37% commercial or other, 12% Medicaid, 7% workers’ compensation and 2% uninsured or self-pay.

Practice operations

As a Better Performer in operations, MBJ surpassed MGMA’s criteria in the following areas:

• Less than the median for percentage of total A/R over 120 days (MBJ: 5.76%; median for ORS: 27.82%).
• Less than the median for days adjusted FFS charges in A/R (MBJ: 60.13 days; median for ORS: 142.58).
• Greater than the median for adjusted FFS collection percent (98.41%; median for ORS: 94.13%).

Contributing to MBJ’s success in these areas were effective EHR and technology adoption, embrace of value-based care, strong referrals, tracking no-shows and controlling costs.

EHR, technology and patient satisfaction

MBJ went live with its EHR in 2016, and the practice has separate EHRs for orthopedics and physical therapy. At the time of adoption, its EHR platform was dermatology-based, so the practice worked closely with its vendor to meet its needs as an orthopedics practice. The platform was also iPad native, which has allowed physicians more flexibility in carrying the devices with them in the practice.

While still working toward full EHR integration, Spencer said several features have helped transform quality reporting and documentation, such as voice recognition and MIPS solutions. “Whatever field you’re in in the EHR, you can click on a microphone and talk right into the iPad,” Spencer said, who added that MBJ’s physicians enjoy the voice recognition they can use while meeting with patients.

MBJ also uses dashboards to help assess patient satisfaction surveys. Poor reviews or comments are flagged in real time, and notifications can be received even as patients are in the waiting room. These reviews then go to a process improvement committee consisting of staff from different departments. “Any time there is a bottleneck or an issue we get all departments involved so that we can do process improvement brainstorming,” Spencer noted.

The practice also has a financial counselor who provides estimates to patients about their out-of-pocket expenses for surgeries, MRIs and pain injections, so they know where they stand with their deductible and coinsurance prior to a procedure. “We get a 50% deposit paid before the surgery or the procedure and then we set up a payment plan for the rest,” Spencer explained. “The patient can focus on healing and then they don’t have any surprises.”

While the use of apps is not widespread in the practice, some physicians use one for e-prescribing. MBJ also recently introduced an app to text patients waiting in their cars for appointments, in response to COVID-19.

Value-based care

MBJ began participating in MIPS before reporting became mandatory in 2019. The practice also participated in the BPCI Advanced Model, which led them to share cost information and best practices with physicians regarding skilled nursing facilities (SNFs), inpatient rehab facilities and rural hospitals that only have step-down units. “For the physicians to understand the cost of where they are sending patients has been a big eye-opener for all of us, which we never had before being in that program,” Spencer stressed. 

As for commercial payers, MBJ is just starting with value-based care in its surgery center with bundles and case rates, but the practice is not signing up for any risk programs during the COVID-19 pandemic. “We’re just doing the implants and the facility fees, but that’s been working out really well so far,” Spencer said.

Referrals

MBJ tracks referral sources through its practice management system (PMS), as well as tracking referring physicians and primary care physician (PCP) information through the EHR.

In addition, the practice has a full-time marketing employee who analyzes trends, such as performance of radio and other advertising. “If a referring physician drops off in referrals, she’ll make an inquiry to see what’s going on,” Spencer said. Other helpful tools the practice used before COVID-19 to target referrals were its lunch and learn program and breakfast with its physicians. This “got our doctors some face-to-face time with the [PCPs]. … They would give us a topic they were interested in and wanted to learn more about,” Spencer noted. “It was amazing how referrals would pick up after that face-to-face time and education.”

MBJ also surveys its referring providers to receive feedback on PCPs about what the practice is doing well and opportunities for improvement. For example, MBJ uses feedback to establish a dedicated physician line for referring physicians who are having a difficult time connecting with the practice; getting patient notes back in a timely manner; and/or working to bring out-of-network payers into the network based on referring physicians’ feedback.

Open slots and tracking no-shows

MBJ has a waiting list for filling open slots in its schedule. The practice also tries to spread out scheduling, particularly during COVID-19, to avoid crowding the office and maintain social distancing. This scheduling also allows for providers to see walk-in patients from the practice’s urgent care.

Finally, as Spencer related, “sometimes we’ll double-book if there is a potential no-show patient … and we have a policy for two no-shows and then they are potentially discharged.” However, the providers have discretion in sending no-show letters or implementing the two-strike policy.

Controlling costs

While Spencer credits MBJ’s talented staff for their work in controlling costs, three key areas she points to are:

1. Getting approval for all non-essential items for business operations
2. Reviewing most visits and all surgeries to ensure proper coding and appropriate modifiers are included prior to billing
3. Utilizing a claims scrubber to ensure claim accuracy. “That automation has really helped with making sure our claims are clean,” Spencer said, noting that rejected claims are addressed on a daily basis so they don’t accumulate.

Practice culture and leadership

Another key aspect of MBJ’s success has been its culture, which has been a priority since Spencer joined the group 12 years ago. “Our mission is dual purpose: to be the orthopedic specialist of choice in our area and the employer of choice in healthcare,” Spencer emphasized. MBJ’s tagline describes how the organization wants to be perceived: “It’s great care from people who care.” This is not only reflected in the practice’s reputation in the community but also the pride employees take in working for the group.

Like many practices, MBJ offers several perks to its employees, including:

• Flexible schedules to help with work/life balance (most employees have a four-day work week)
• A fun committee organizes events such as barbeques, picnics, lip sync battles, outdoor game nights, tailgate parties, bowling nights.

“Not only do we survey our patients, we also survey our employees,” said Spencer about gauging employee job satisfaction and making improvements based on their feedback.

As for organizational leadership, MBJ has working supervisors in each department who have a finger on the pulse of employees, as well as a management team composed of Spencer, an operations manager, a finance manager and a surgery center clinical director. According to Spencer, frequent communication is another key to practice success: “We have department meetings to make sure people are heard, we have townhall meetings to share information and answer questions, we do an employee newsletter for any updates … and then most of the supervisors will do weekly email updates so that everybody is hearing the same information.”

Responding to COVID-19

Missoula Bone & Joint rebounded quickly from the initial wave of COVID-19, but it took a lot of effort from the entire team. As Spencer noted, the list of challenges was extensive and included education; preventive measures; keeping staff and patients safe; managing a shortage of personal protective equipment (PPE); financial struggles, including assessing and applying for federal relief; and understanding the Families First Coronavirus Response Act (FFCRA).

For Spencer, the biggest challenge may have been “evaluating and monitoring all the changing information that comes out every day … whether it’s CDC recommendations, your county health department, or whatever study or journal article you read.”

Despite fewer COVID-19 cases in Montana, the practice still had to close its surgery center for a month — save for a day and a half each week for emergencies — and furlough some staff.

However, after receiving a grant from the Department of Health & Human Services (HHS) as part of the CARES Act and a PPP loan, MBJ was able to bring staff back. “We let people volunteer; some people needed be home for their kids, and we had some people who were compromised or who had family members who were compromised,” Spencer said of the furloughs. “Nobody felt like they were forced.”

Unlike many practices, MBJ did not make a sweeping transition to telehealth. In fact, only the primary care sports medicine physician has predominantly used telehealth during COVID-19. Per Spencer, other than some post-op work with patients, the practice’s orthopedic surgeons weren’t able to participate due to poor internet connections for many rural patients and the need to conduct in-person physical exams. In all, telehealth resulted in less than 5% of total visits during the pandemic thus far.

During the stay-at-home period through April, MBJ’s volume dropped 50% to 60%. As a result, the practice instituted a spending freeze on non-essential business operations, including marketing, charitable contributions and capital expenditures. Additionally, the practice put a hold on some benefits, such as 401(k) contributions and education expenses, and froze merit raises and merit bonuses (which have since been reinstated).

As for expenses, the practice had to purchase masks for patients and employees, sanitizer, extra cleaning supplies, N95 respirators, face shields, regional anesthesia, an app to text patients and plexiglass for reception desks. “One of the biggest expenses was staffing the screening stations at our four entrances,” Spencer said, noting that the practice has already spent more than $50,000 on that. These staff members are vital in that they ask screening questions, take patient temperatures, sanitize the waiting room and wipe down high-touch areas.

Despite these expenses and the drop in patient volume, when the State of Montana reopened, volume ramped up fairly quickly. As of early August, MBJ is at 90% volume in its clinic and back to pre-COVID-19 levels in its surgery center. “I think the reason we’re back to normal in the surgery center is because patients do not want to go to the hospital,” said Spencer. “And we were closed for a month doing only emergency cases, so we had a backlog.”