CODE speaking with Dr. R. Lor Randall, MD, FACS at the 4th Interdisciplinary Conference on Orthopedic Value Based Care 2020

Session Topics:

  • Extreme Affordability: Orthopedic Surgical Innovations
  • Orthopedic Value-Based Cancer Care

Interviewee: 
Dr. R. Lor Randall, MD, FACS – Orthopaedic Surgery
Professor & Chair, Department of Orthopaedic Surgery
University of California, Davis

Dr. Brian Cunningham:
Okay, Welcome to OVBC 2020. We’re very fortunate today to be joined by Dr. Lor Randall, now the Chairman at UC Davis. Thank you so much for a little bit of your time. Just had a fantastic talk on the role of value in orthopedic oncology. Give us a little bit of insight on kind of where you start thinking about that in your clinical practice.

Dr. R. Lor Randall:
Well, as was alluded to, we spent a lot of time taking care of a lot of different conditions. And we take care of children all the way up to adults, and we deal with lots of different conditions. We’re disease-focused, as I was saying before, disease-focused, mostly demographic or anatomy focused. And so we take those simple aspects of the value equation, the numerator is basically Patient-Reported Outcomes and patient satisfaction. Look at those, dive into those with the disease we’re treating, and then also with the processes and the reconstructions that we do, how can we drive down the cost. One thing that I’m not talking about this meeting, but I think is important is we’re critically looking at the use of CT scans and surveillance for lung metastasis in patients with sarcoma. Sarcoma is the most frequent site of metastasis, the lung, and we’re looking at how we can maybe potentially certainly get chest CTs without IV contrast or potentially even use chest radiographs to screen these patients.

Dr. Brian Cunningham:
Fantastic. Very interesting. Your talk that you gave this morning or this afternoon was great, focused on kind of thinking about tailoring reconstructions or at least being aware of some of the costs and the effects. When you’re dealing with the patient, how do you go about making that decision? Give us some insight into your kind of thought process.

Dr. R. Lor Randall:
Sure. Well, in that domain, which is again, children, we do a lot of listening. We invariably have to schedule these for the end of the clinic.

Dr. Brian Cunningham:
Sure.

Dr. R. Lor Randall:
Otherwise, our Press Ganey scores go down for all the wait time. Right? And it’s a process, without getting into it in too much detail, these families are going through a lot. Their loved one, their young ones has been diagnosed with cancer. The first thing is their life, right? And then they start to think about the other consequences. And so you do a quick fly-by, if you will, of all of the things. We’re going to get the tumor out, we’re going to do what we can to maximize function. We can do fancy technologies. We’re going to do some more simple things. Just warm up the idea.

Dr. Brian Cunningham:
Yeah.

Dr. R. Lor Randall:
The internet is really accessible. Obviously, these families sometimes come into the first interview or first meeting, I should say, having already scoured the internet for things. Rotationplasty, which is what I spoke about before, I’m hearing more and more about the first engagement with the family about rotationplasty from them. I’m not having to introduce them. 10 years ago, I’d have to couch it in the concept of, “I’m going to talk about something that’s pretty startling here. Just keep your mind open. We’ll revisit it in detail the next time.” But now, before I get to the comments starling, the mom or dad will pipe in, “You’re talking about rotationplasty, aren’t you?” But anyway, to your point, there’s no one way to do it. We have to do a lot of listening about their expectations and that’ll tie in obviously then to their satisfaction and as well as their PROs.

Dr. Brian Cunningham:
Yeah. Fantastic. So to me, I hear in some ways kind of what I would call some shared decision making and that kind of it’s prolonged and it’s much different in your setting than it would be safe for a hip replacement. But talk a little bit about, how does the… We talk about stakeholders in the sense of, “Oh, it’s payers or it’s patients and it’s positions.” But when you’re dealing with a family of a young person and they have this diagnosis, it’s complex. How do you talk about providing value to the family members, the patient, kind of the whole ecosystem versus just it’s much simpler when it’s, “Oh, you need a hip replacement?”

Dr. R. Lor Randall:
So again, for the value part of this, I just focus on the shared decision making in the domain of what is little Johnny or Jane wants to do with his or her next five (5) years, and what do they want to do? What’s the vision longterm? Because those matter when we’re dealing with these interventions in children that are hopefully going to survive their disease.

Dr. Brian Cunningham:
Right.

Dr. R. Lor Randall:
It used to be that Orthopedic Oncologist would do this procedure just to sort of giving them some functionality for a few years because they would succumb to their disease. And now, we’re winning the battle three (3) out of four (4) times from an oncologic standpoint. So we have to have the discussion about, what does life looks like for the rest of your life with this orthopedic intervention? And so we really have to emphasize that it’s really how your leg looks versus how your leg functions, which isn’t necessarily the same thing, then we go in different directions.

Dr. Brian Cunningham:
That’s fantastic. As a leader of an academic institution, how has your department as a whole kind of starting to think about value? And I’m sure you guys have done a lot of things, but just as an example. Maybe over the last ten (10) years, where do you think the biggest changes have happened?

Dr. R. Lor Randall:
Well, to your first query, I’m delighted that you asked that. I almost feel like I planted that on you because it’s something that I’ve taken to heart. We started a strategic plan. The faculty derived a strategic plan last spring. In fact, we got together and build it out. Four (4) pillars, one of which is the clinical pillar and it’s the title of that clinical pillar is World-class Value-Driven Healthcare. Everything we do is value-driven. We apply the value equation to everything. And we have a Chief Value Officer now.

Dr. Brian Cunningham:
That’s fantastic.

Dr. R. Lor Randall:
You probably know Phil Wolinsky, he was the Trauma Chief. He was looking for another leadership position and this is great because he’s done hip fracture work and value. So he’s now working with all the sections to tailor a value project for each section. So each section is required every year for sort of their merit-based considerations to have a value project. And it’s the first year we’re doing it, and we keep it very loose. We say, “Look, here’s the value equation. It can be as little as dropping down the price you guys use on some implants the first year. But every year, we need to move the needle of increase in the numerator and decrease in the denominator.” And we really feel like we’re leading the health system in that way.

Dr. Brian Cunningham:
That’s fantastic. I mean, I don’t know that there… Is there other places in the country-

Dr. R. Lor Randall:
Well, I came from a place that was really leading in this. So the University of Utah’s really been a stakeholder in this domain, too.

Dr. Brian Cunningham:
Yeah. That’s fantastic. I love the idea of making, encouraging people, sections to do a project every year to really kind of continue to push the envelope and innovate.

Dr. R. Lor Randall:
And one thing along with that.

Dr. Brian Cunningham:
Yeah.

Dr. R. Lor Randall:
When I first brought up the term value, they thought it was, no pun intended, cheap. They thought it was denigrating like you were going to… “What do you mean value? Aren’t you talking about quality?” And I said, “Yes, I’m talking about quality.”

Dr. Brian Cunningham:
That’s right.

Dr. R. Lor Randall:
Quality is part of the value.

Dr. Brian Cunningham:
That’s right.

Dr. R. Lor Randall:
But if you want to talk about quality, that’s very important. Let’s make the quality better. And in so doing, you’re improving the value.

Dr. Brian Cunningham:
That’s awesome. What did… From looking specifically around total joints, there’s been a ton of talk at this meeting about leaders of departments thinking about building ASCs and how to move arthroplasty outpatient or keep an inpatient and who’s going to do it. And Dr. Cohen talks about the big super busy, very productive academic surgeons having a harder time because they’ve got two (2) fellows. Then they got a highly oiled machine versus some of the younger guys in the community, people having a little bit easier time. What’s your guys’ experience been at Davis with kind of the progression of total joints?

Dr. R. Lor Randall:
Great question. Again, I feel like I’ve loaded that into the queue. I’m really appreciative of that. So we have a new vice-chancellor, David Lubarsky, who actually presented here last year and he’s very passionate about this. And I came into a medical center that’s world-class in trauma, but also world-class in other aspects of orthopedics. But they were literally and figuratively bumping into each other, still are in the sense that we’ve got the one really great hospital. But we’ve got a trauma mission and sometimes it encumbers the scheduled cases.

So we’re working through that and Dr. Lubarsky approached me about ambulatory surgery and trying to facilitate our same-day surgery center, which isn’t a 23-hour facility right now. And we are about to go live actually, hopefully, April 1 or April 2, not April Fool’s Day, with an ambulatory program. And so are our three (3) arthroplasty surgeons, who are terrific, had been working. We meet weekly at 7:00 AM with our section chief and the whole healthcare system to work on how for the first few months, we’re going to do ambulatory arthroplasty in the hospital, which you can imagine, we could spend an hour talking about that.

Dr. Brian Cunningham:
No question.

Dr. R. Lor Randall:
But then we’re going to transition that to our same-day surgery center. And ultimately, we’re going to build an ambulatory surgery center to facilitate that. But I think if I’m so fortunate to come back and do this again next year, we’ll have to close the loop on how we’re doing on that front.

Dr. Brian Cunningham:
Fantastic. Well, thank you so much for a little bit of your time. We’re here at OVBC 2020. And for everybody considering it, it’s a fantastic meeting and you get to hang out with people like this and open your mind.

Dr. R. Lor Randall:
It’s really a privilege. Thanks so much.

Dr. Brian Cunningham:
Thank you.

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