Impact of an integrated practice unit on the value of musculoskeletal care for uninsured and underinsured patients

Background: Limited access to specialty care for uninsured and underinsured patients may be exacerbated by traditional fee-for-service approaches to care that incentivize volume and intensity of services over value of care. The purpose of this study was to determine the impact of a value-based integrated practice unit (IPU) on access to musculoskeletal care and surgical outcomes in a safety-net population. Methods: A new IPU was implemented on 6/1/2016 at an established safety-net clinic providing musculoskeletal care in central Texas to supplement existing musculoskeletal care provided through a fee-for-service model. This retrospective cohort study compared access and outcomes under the IPU to the parallel fee-forservice clinic through 3/31/2017, as well as the historical fee-for-service clinic from 8/1/2015 through 5/31/2016. Primary outcomes for access included number of referrals addressed; for surgical patients, length of stay, discharge destination, and 30-day readmission rates were assessed. Results: The baseline waitlist of 1401 referrals on 6/1/2016 was eliminated by 3/31/2017. Among patients undergoing hip or knee replacement, length of stay was 1.4 days compared to 2.6 days for patients referred to the parallel fee-for-service clinic (p < 0.001), and 92% were discharged home versus 89% (p=0.46). The 30day readmission rate for the IPU was 2.7%, which did not differ significantly from the HFFS (8.5%, p=0.23) and PFFS (3.7%, p=0.64) clinics. Conclusions: An IPU increased access and improved short-term surgical outcomes in a population of uninsured and underinsured patients seeking musculoskeletal care. Additional studies of longer duration are needed to assess the sustainability of a value-based approach. Implications: A value-based approach to musculoskeletal care may improve access and outcomes in safety-net patients.