Issue: October 2017
October 06, 2017
9 min read
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Changed setting for joint reconstruction surgery possible in 2018

CMS proposal revives discussions about safety, efficacy of outpatient surgery.

Issue: October 2017
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On Sept. 11, CMS closed the comment period on a proposal to remove total knee arthroplasty and some partial and total hip arthroplasty CPT codes from the inpatient-only list in 2018, which may allow more Medicare beneficiaries to undergo these procedures on an outpatient basis. The proposal was released July 13 with the 2018 Hospital Outpatient Prospective Payment System and ASC Payment System proposed rule.

Richard A. Berger, MD, who has performed outpatient total knee arthroplasty (TKA) and total hip arthroplasty (THA) for more than a decade in patients with private insurance, believes removing partial and total joint arthroplasty (TJA) from the inpatient-only list is a step CMS should have taken years ago.

“We are trying to save the system money. We are trying to do what is right for the patient, the patient who wants to go home,” Berger, assistant professor of orthopedics at Rush University Medical Center, told Orthopedics Today. “Medicare will pay if [the patient stays] 3 days in the hospital, but if [the patient goes] home 3 hours later, they will not pay, which has been ridiculous. So, for me, this is great. This is wonderful.”

“The inpatient-only list is a list of procedures that are typically provided only in an inpatient setting and, therefore, not paid by Medicare under the [Outpatient Prospective Payment System] OPPS,” a CMS spokesperson told Orthopedics Today. “We review the inpatient-only list each year to determine whether or not any procedures are safe to be performed in the outpatient setting for a Medicare beneficiary and therefore should be proposed to be removed from the list.”

Kevin J. Bozic
Kevin J. Bozic, MD, MBA, said outpatient total joint replacement requires different resources than inpatient surgery. Outpatient surgery has become simpler and safer with the evolution of surgical techniques and improvements in perioperative management programs.

Source: Shannon Southerland

Techniques and methods evolve

Alexandra E. Page
Alexandra E. Page

According to Kevin J. Bozic, MD, MBA, professor and chair of the department of surgery and perioperative care at Dell Medical School at the University of Texas at Austin, this CMS proposal is part of the natural evolution that occurs as surgical techniques and perioperative management programs improve with time. He said that as these procedures become simpler and safer, migration to the outpatient setting for certain patients is both natural and appropriate.

Adolph V. Lombardi Jr., MD, president of Joint-Implant Surgeons, said a change like this would have been “heresy” 30 years ago when he started in orthopedics not to mention discharging a patient the same day that he or she underwent arthroscopic ACL reconstruction.

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“Today, if you kept the patient, you would be criticized,” he told Orthopedics Today.

Making TJA safer

Despite concerns about TJA performed in an ambulatory setting, TJA can be performed safely in an outpatient setting and patients fair well postoperatively, according to Lombardi.

Berger said healthy patients who undergo outpatient TJA experience fewer complications and have lower pain scores, as well as higher patient satisfaction scores and a quicker recovery time.

“Patients recover quicker not just because ... of minimally invasive surgery, but patients are recovering quicker because they are home and they are comfortable and they are happy at home,” he said.

One reason outpatient orthopedic surgery has advanced is the improved partnership and cooperation between orthopedic surgeons and their anesthesia colleagues, according to Orthopedics Today Chief Medical Editor Anthony A. Romeo, MD.

“We now know how to manage and control our patients in the outpatient setting for pain, nausea and awakeness in a way that allows procedures considered to be more painful, like a knee replacement or a hip replacement or a shoulder replacement, to be done in the outpatient setting,” Romeo said.

Many healthy patients will experience more efficient care in an ASC compared to a hospital, he said.

A large tertiary care hospital has various services, resources and departments associated with it, which “is probably not the best place to render care for an otherwise healthy, normal patient who just needed a knee replacement,” Berger said. “That can be rendered better in a small ambulatory care center that does not need all the services a big hospital has to have for their sick patients and, therefore, it will be more cost-effective.”

Investment in outpatient care

Adolph V. Lombardi Jr.
Adolph V. Lombardi Jr.

There are more than 5,000 Medicare-approved outpatient facilities, according to Romeo, who said some facilities have limited their investments in TJA outpatient procedures because these are not currently approved by CMS, and this has led to fewer patients undergoing outpatient TJA.

“There is a certain critical mass of procedures that a practice or facility needs to perform in order to justify the investments that are required to have an outpatient TJA practice,” Bozic said. “Outpatient surgery looks different from inpatient surgery and requires different resources. As a result, some practices have been reluctant to invest in outpatient TJA programs, not knowing if it was only going to remain a boutique part of their practice for a small percentage of commercially insured patients.”

Facilities that want to be better prepared to perform outpatient TJA should focus on infrastructure and obtaining the appropriate equipment, Romeo said.

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“In centers that are performing TJA on an outpatient basis already, they have developed the infrastructure, which includes multiple sterilization devices, as well as a systems approach to ensure that they limit the number of trays or equipment necessary to safely perform these procedures,” he said.

Sources said ASCs and outpatient facilities should develop after-surgical care systems like ones used in the inpatient hospital setting, which include additional care coordinators, more intensive post-discharge resources and greater coordination with home health care.

David A. Wong
David A. Wong

Berger said, “Get a team together of nurses and therapists and discharge planners and go over all of the things your inpatients would need. You still must provide that for those outpatients. Then you have to develop a system that will work for your practice to put in place, to be able to provide all of those services to the patient that used to be provided by the hospital.”

Beyond the infrastructure to perform outpatient orthopedic surgery, surgeons need to be comfortable with the procedure, Scott D. Boden, MD, director of the Emory Orthopedics and Spine Center and Spine Section Editor for Orthopedics Today, said.

Berger recommended initially performing outpatient surgery in young, healthy patients prior to attempting outpatient surgery on older, Medicare patients or patients with comorbidities.

Although outpatient surgery is safe, it is not safe for every patient. The surgeon should “be the one who is the final arbitrator in terms of what is the safest site of service for a patient,” said Alexandra E. Page, MD, chair of the American Academy of Orthopaedic Surgeons Health Care Systems Committee.

Using risk stratification tools, surgeons can identify which patients would be best to undergo outpatient surgery prior to the procedure, according to Page.

“You have to factor in [patient] age, [patient] comorbidities ... and you have to factor in the patient’s support system,” Bozic said. “Patients who have multiple medical comorbidities or patient who do not have an identified co-pilot to help them after surgery are patients who probably are not ideal for the outpatient setting.”

Sources told Orthopedics Today about their concerns of retaining flexibility to be able to perform TJA in an inpatient setting once it has been removed from the inpatient-only list.

“One of the potential concerns is, if you move [TJA] completely off the inpatient-only list, does it become an uphill battle when you have patients who need a higher level of care?” Page said. These might be patients whose postoperative care you worry about and who might be best treated in the inpatient setting, she said.

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The hospital’s voice

Richard A. Berger
Richard A. Berger

Some hospital leadership has argued that total joint procedures are not safe when performed in the outpatient setting, but this is not always the case, according to Bozic.

“The hospital lobby is concerned about this issue because hip and knee replacement procedures have been a major contributor to hospital margins for the past several decades, and even the threat of taking that away or making other options available, is economically threatening to hospitals,” Bozic said. “As would be expected, they are going to make all of the arguments about why it is unsafe to do these procedures in the outpatient setting, which may be true for certain patients, but evidence has shown that many of these procedures can be safely and efficiently performed in the outpatient setting.”

Romeo said the possible decision to move some inpatient-only orthopedic joint and spine surgery to the outpatient surgery list may make some physicians nervous, based on where they work. Physicians who work in an academic medical center usually do not have the opportunity to develop an outpatient facility, and this update may threaten their practices, he said.

On the other hand, he noted orthopedic surgeons in private practice may see this change as an opportunity for their patients and their practice.

“If you are a private practicing orthopedic surgeon, that is more than two-thirds of the orthopedic surgeons out there, and you have the opportunity to have some control over your operating environment, such as your ASC, you see this as a progressive positive movement forward and an opportunity to gain greater control over your surgical services that you offer to your patients,” Romeo said.

According to Page, it is anticipated CMS will have Medicare patients undergo outpatient surgery in a hospital outpatient department before these types of patients can undergo the same procedures in an ASC. The understanding is this intermediary step would help bridge the gap in transitioning from an inpatient-only setting to an outpatient setting.

“I think there are a number of procedures that can be done safely whether it is in an ASC, which has a little less resources and backup, or in a hospital operating setting,” Boden said. “The issue is just a question of how long patients stay under observation after the procedure. There are some ASCs that have 23-hour observation beds where [patients] actually stay overnight and go home the next day. I think there is clearly more than one set environment to be able to do these procedures,” he said.

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Future moves

Scott D. Boden
Scott D. Boden

Should CPT codes for certain TJA procedures make it on to the CMS outpatient surgery list, sources said that could help pave the way for other orthopedic procedures to move off the inpatient-only list.

“I believe strongly that the change of TKA to an outpatient procedure, thereby removing it from the inpatient-only [list], is the tipping point for a mass migration of many other procedures out of the hospital setting,” Romeo said.

Lombardi said he thinks straight forward revisions, such as THA polyethylene liner exchanges, will eventually be performed in an outpatient setting.

David A. Wong, MD, MSc, FRCS(C), Orthopedics Today Editorial Board Member, said minor spine procedures have gradually been making their way to the outpatient setting.

“On the spine side, [outpatient surgery is], generally speaking, in the lumbar discectomy/one- or two-level decompression-type procedures. For the neck, anterior discectomy and fusion procedures [ACDF] are the most common. Disc arthroplasties are also being shifted to the ASCs, as well, since there is a comparable degree of surgical intervention and blood loss to ACDF,” Wong told Orthopedics Today.

In a letter sent to CMS on Aug. 30, the American Association of Orthopaedic Surgeons requested the removal of several additional procedures from the inpatient-only list and adding them to the ASC list. These procedures include total ankle arthroplasty or total ankle replacement, revision total ankle arthroplasty, total shoulder arthroplasty and shoulder hemiarthroplasty.

Orthopedics outpatient surgery

Rotator cuff repair and shoulder instability surgery and some shoulder fracture procedures are already performed outpatient, Romeo said. The one category in the area of the shoulder that is not currently approved for outpatient as listed on the inpatient-only list is shoulder arthroplasty, he said. Because inpatient procedures continued to be adapted for outpatient surgery, Wong said some surgeries are best kept as inpatient surgery.

“You have to look at the degree of surgical intervention with clearly something that is going to keep people in the hospital and require a big effort from physiotherapy and occupational therapy to get them back to their activities of daily living. That is the kind of [case] that is clearly better done in the inpatient hospital setting where those kinds of services are available and the timeframes to get people to that level of function are more appropriate for their situation,” Wong said. – by Casey Tingle

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Disclosures: Berger reports he receives royalties from MicroPort and is part owner of an ASC. Bozic reports he is a consultant to the Yale New Haven Hospital for Outcomes Research & Evaluation or CORE, which is a measure developer for CMS. Lombardi reports he owns an outpatient surgery center. Romeo reports he has part ownership in an ASC. Boden, Page and Wong report no relevant financial disclosures.

Click here to read the POINTCOUNTER, “Should CMS do step-wise introduction of outpatient procedures for Medicare patients, allowing the procedures to be done at a hospital outpatient department and if deemed safe, clearing them to then be done at an ASC?