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Issue: August 2021
Source: Changed setting for joint reconstruction surgery possible in 2018. Available at: www.healio.com/news/orthopedics/20171005/changed-setting-for-joint-reconstruction-surgery-possible-in-2018. Accessed July 14, 2021.
Disclosures: Hamilton reports he has ownership in an ASC and is a consultant and participates in product development for DePuy Synthes and Total Joint Orthopedics Inc. Meneghini reports he receives royalties and licensing fees from DJO Global for an outpatient risk assessment tool and has ownership in an ASC. Murrey reports he is employed by Surgical Care Affiliates. Sperling reports he receives royalties for shoulder arthroplasty design from Zimmer Biomet. Boden and Roh report no relevant financial disclosures.
August 16, 2021
11 min read

Changes in policy, protocols advance outpatient surgery

Issue: August 2021
Source: Changed setting for joint reconstruction surgery possible in 2018. Available at: www.healio.com/news/orthopedics/20171005/changed-setting-for-joint-reconstruction-surgery-possible-in-2018. Accessed July 14, 2021.
Disclosures: Hamilton reports he has ownership in an ASC and is a consultant and participates in product development for DePuy Synthes and Total Joint Orthopedics Inc. Meneghini reports he receives royalties and licensing fees from DJO Global for an outpatient risk assessment tool and has ownership in an ASC. Murrey reports he is employed by Surgical Care Affiliates. Sperling reports he receives royalties for shoulder arthroplasty design from Zimmer Biomet. Boden and Roh report no relevant financial disclosures.
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December 2020 saw CMS finalize a proposal to eliminate the inpatient only list in a 3-year transitional period, which allowed about 300 primarily musculoskeletal-related services to be performed in the hospital outpatient setting.

The 2021 Medicare Hospital Outpatient Prospective Payment System and ASC Payment System final rule also added 11 procedures to the ASC-covered procedures list, including total hip arthroplasty. These CMS policy changes, which started with removal of total knee arthroplasty from the inpatient only list in 2018, combined with a refinement of surgical and patient management protocols in the last 5 to 10 years, have led to a shift from performing orthopedic procedures in an inpatient setting to an outpatient hospital or ASC setting, according to William G. Hamilton, MD, of Anderson Orthopaedic Clinic and Anderson Orthopaedic Research Institute.

R. Michael Meneghini, MD
R. Michael Meneghini, MD, said successful outpatient surgery requires patients be educated about their medications, as well as about how to minimize any complications and why postoperative home support is necessary.

Source: R. Michael Meneghini, MD

In addition, patient education and demand added to the sharp increase in orthopedic procedures being performed in outpatient or ASC settings, Jeffrey S. Roh, MD, CEO of IntuitiveX, said. There is also increased interest in this area now that surgeons have found innovative ways to perform these procedures, he said.

What began as mild interest among surgeons and patients in this shift in surgical site, later “spread like wildfire,” according to Hamilton, who said the shift to outpatient surgery seemed to speed up “over the course of the past 1 to 2 years.”

William G. Hamilton, MD
William G. Hamilton

Sources who spoke with Orthopedics Today said the COVID-19 pandemic may be a factor that accelerated the shift to surgery in an outpatient or ASC setting that was underway before the onset of the pandemic.

“The shift was already in place, but it was only accelerated by COVID-19, where there was the desire among hospitals due to decreased bed capacity to transition to outpatient joint arthroplasty, as well as patients who had a preference for minimizing their time in the hospital and also preferred to pursue joint arthroplasty as an outpatient procedure,” John W. Sperling, MD, MBA, professor of orthopedic surgery at Mayo Clinic in Rochester, Minnesota, told Orthopedics Today.

With the desire to keep patients out of the hospital, Hamilton noted surgeons started to become more comfortable and flexible about which patients would undergo outpatient surgery. Despite a return to pre-pandemic standards as restrictions were lifted and cases of COVID-19 were reduced, Hamilton said outpatient orthopedic procedures, specifically total joint procedures, have started to become the norm in some communities as comfort levels of surgeons and patients changed.

“Performing outpatient surgery during the pandemic started to open our eyes to what can be done,” Hamilton, an Orthopedics Today Editorial Board Member, said.

Protocol, patient selection changes

Prior to COVID-19, for outpatient surgery to grab a hold in orthopedics, spine surgeon Daniel B. Murrey, MD, MPP, chair of the Health Care Systems Committee of the American Academy of Orthopaedic Surgeons, said physician champions were needed to lead the way in finding a safe and efficient way for it to be done.

Daniel B. Murrey, MD, MPP
Daniel B. Murrey

“We saw emerging over the last decade a number of physician champions who took this on to try to figure out what is the best way to transition those cases to the outpatient setting and the ambulatory surgery environment,” Murrey told Orthopedics Today.

According to Murrey, challenges that had to be overcome for outpatient surgery to be successful included establishing new pain control protocols, avoiding techniques that limited mobility or created challenges with early discharge and establishing anesthesia protocols that reduced the incidence of postoperative nausea and urinary retention.

R. Michael Meneghini, MD, director of Indiana University Health Hip and Knee Center and professor of clinical orthopedic surgery at Indiana University School of Medicine, said patients may also have to be more stringently selected to undergo a procedure at an ASC that is not affiliated with or in close proximity to a hospital.

“It is inappropriate to have a patient who is older and frailer, has multiple medical comorbidities struggling in the postoperative care unit and fails to discharge from an ambulatory surgery center,” Meneghini, an Orthopedics Today Editorial Board Member, said. “Many freestanding ASCs do not have overnight capacity or hospital beds. They do not have a ‘safety net’.”

He said patient selection will become more important as Medicare patients with more medical comorbidities have surgery in the ASC setting.

“We need to look at these patients’ medical comorbidities. Is their diabetes controlled? Do they have obstructive sleep apnea where they might have low saturations if they go home and are not monitored?” Meneghini said. “That medical risk mitigation and management process must be robust so that the older Medicare patients are able to be done safely without increasing the complication rates.”

However, as surgeons become more familiar with outpatient procedures, they will be able to identify the best candidates for these procedures with more certainty, he said.

“Over time, my assumption is that more of these procedures will be done on an outpatient basis,” he said.

Patient, surgeon education

With discharge to home after outpatient surgery, Meneghini said it is important to educate patients on their medications and how to minimize complications ahead of time in the preoperative process.

The patient’s education should also include a discussion of the importance of home support after surgery, he said.

“We have to make sure someone is going to be with that patient overnight, that they are a reliable person and that [the patient has] a good environment to go to because they are not going to be in the hospital,” Meneghini told Orthopedics Today.

Sperling prefers patient education for an outpatient procedure be provided preoperatively, not postoperatively.

John W. Sperling, MD, MBA
John W. Sperling

“That way the patient is comfortable, is clear on the rehabilitation program, they know how to place their sling and they know how to properly take care of their shoulder replacement,” said Sperling, an Orthopedics Today Editorial Board Member.

Meneghini said it is important that surgeons and hospitals are educated in the best way to keep patients safe during and after an outpatient procedure.

“We call the majority of our patients the next morning to make sure they are doing OK. It is like rounding by phone, if you will,” Meneghini said. “We have a health patient engagement app that they can [use to] email us any time they want. They email us back and forth and they have access to me 24/7 by phone. These are processes we are trying to make sure ASCs and institutions implement and have in place prior to launching an outpatient joint replacement program.”

Physician ownership

The capability of physician ownership in and management of an ASC has also driven more orthopedic procedures to be performed as outpatient, according to sources who spoke with Orthopedics Today. Not only has this led to an increase in happiness and satisfaction among both surgeons and patients, but it has also provided physicians with ancillary income, which may help combat consistent reductions in physician reimbursement for performing the surgery, Hamilton said.

“We are all ethically bound to make sure we are not referring based on ownership. However, once surgeons have a role in managing the operations and efficiencies of an ASC, it can lead to an improved experience for both patient and surgeon. As surgeons experience the pleasant environment of an ASC and see the benefits for their patients, they may choose to take more of their patients there over time,” Hamilton told Orthopedics Today.

Although revenue sharing from running an outpatient surgery center is an added benefit to physicians, Scott D. Boden, MD, professor and chair in the department of orthopedics at Emory University School of Medicine and vice president for Business Innovation for Emory Healthcare, said this may lead to a drain on resources provided by general hospitals.

Scott D. Boden, MD
Scott D. Boden

“Unfortunately, the trend is a little bit worrisome in terms of the financial model that helps support care for pneumonia and other things that people get admitted to the hospital for without some of that revenue and margin from the operating room,” Boden, Spine Section Editor of Orthopedics Today, said.

Joint ventures

Some hospitals have recognized this challenge of losing patient volume with the growth of ASCs and have embraced the change by entering into a joint venture regarding an ASC with surgeons, Murrey said.

“There are hospitals that have challenges with OR time and capacity and have embraced joint venturing on ASCs that are actually doing outpatient joints,” he said. “Being able to diversify their offerings to patients they know, in the long run, is going to make them more attractive to their patients.”

By creating a joint venture that does not include a third-party capital partner, Boden said hospitals and surgeons would be helping to keep revenue within the health care system.

“At least in a joint venture between a hospital and a group of physicians, some of the money is going to the physician investors, but some of it is still staying within the hospital system,” Boden told Orthopedics Today. “Now, when you have a third-party capital partner working with physician groups, all of those dollars are leaving the hospital system.”

However, when partnering in a joint venture, Hamilton said hospitals and surgeons must collaborate so that it is mutually beneficial for both. This can be done when hospitals engage surgeons with attractive packages that comply with Stark and anti-kickback laws and benefit both the surgeon and the hospital, while surgeons work with the hospital “to maintain the integrity of local health systems,” he said.

“This is a paradigm shift as, historically, hospitals have not involved physicians in profit-sharing initiatives,” Hamilton said. “If a health system fails to recognize these ongoing changes, surgeons may choose to take their cases elsewhere. This can be bad for all parties — hospitals, physicians and the communities they serve.”

Patient-centered care

In addition to keeping revenue within the health care system, joint ventures provide the opportunity to create a health care delivery ecosystem that addresses the needs of older, sicker and less mobile patients; younger, healthier patients; and everyone in between, according to Murrey.

“We talk a lot about patient-centered care, but all too often we have physician-centered care or facility-centered care and not patient-centered care,” Murrey said.

According to Murrey, the Bundled Payments for Care Improvement (BPCI) initiative provides an example of a program that caused surgeons and hospitals to rethink how they delivered care, particularly in regard to total joint arthroplasty.

“The way we used skilled nursing facilities and inpatient rehab facilities dramatically changed for those who went through the BPCI program because we realized we were making decisions based on what was convenient for the facilities, but not necessarily what was patterned directly for those patients’ care,” Murrey said. “It forced us to be a lot more intentional about how we redesigned care for different cohorts of patients, and I think it was a good first step in getting us to rethink all of these ways of doing things.”

Advantages of outpatient surgery

Although the full impact of outpatient surgery on patient care remains to be seen, Hamilton said it will not only improve care, but provide an opportunity for reductions in the overall costs.

Jeffrey S. Roh
Jeffrey S. Roh

“[Outpatient surgery is] going to radically reduce the cost of care because doing it in an outpatient setting is more affordable; it will free up hospitals to do what they do best, which is care for sick patients; and surgeons will, with ownership, be able to get some ancillary income, which is good in a challenging reimbursement environment,” Hamilton said. “I think there are benefits up and down the line for both patients and surgeons, as well as society, because it is going to help bring down costs.”

Outpatient surgery may also promote the use of less invasive procedures because there are restrictions on patients’ length of stay at the facility after surgery, according to Roh.

“You would not consider doing a large open type of surgery in a surgery center because most surgery centers have 23:59 overnight stay capabilities, but not much beyond that,” Roh told Orthopedics Today.

Boden said a lot of the advantages of performing surgery in an outpatient or ASC setting depend on the focus of the surgery center and surgical team and the efficiency of the operation.

“You can provide an excellent patient experience and an excellent surgeon experience in an operating room that is attached to a hospital if you do it right, the same as you can in a freestanding ASC,” Boden said. “There is not anything magic about having an operating room that does not attach to a hospital. It is more about the way it runs.”

Outpatient surgery with value

Surgeons interested in performing outpatient surgery should identify their ability to provide greater value for their patients in a different setting of care, as well as perform a realistic assessment of the facilities they are employed in and whether those facilities support performing outpatient surgery, Murrey said. Surgeons also must perform an honest assessment of their performance, he said.

“Are your safety numbers as good as they have historically been? Is your patient experience as good as it has historically been and can you feel good about that clinical outcome or not?,” Murrey said. “It is important to retrospectively ... look at that and make sure that once you have done it, that you are continuing to iterate and improve on it.”

He said surgeons need to also be willing to put the work into performing outpatient surgery.

“It is always easier to do it the way we have always done it than it is to create a change and have to go through that period of adjustment and train the team and make sure the systems are all in place,” Murrey said. “Any of these changes require a commitment, but once you are there and you get to the new normal, it can be a better place for the appropriate patients.”

Need for hospitals

Surgeons with questions or concerns regarding outpatient surgery should turn to their colleagues who have the most experience in performing outpatient surgery for answers, according to Sperling.

Complications graphic

“This has become a key topic at many of our meetings, trying to learn from those who pioneered doing [shoulder surgery] in an outpatient setting, learning what are the best practices. That way, surgeons do not have to reinvent the wheel,” Sperling said. “They can learn from our colleagues what has been most successful and what have they learned from to make this transition.”

Yet, even as surgery centers become more prevalent, Roh said this does not mean hospitals will become nonexistent or obsolete.

“We will always have need for the sickest of patients with the most complex type of conditions to have their care provided at a hospital system,” Roh said. “But, as we develop more techniques and technologies that allow surgeons to be able to perform similar types of procedures in a less invasive fashion, then we should all be open to the fact that many of these procedures can be done in an outpatient setting.”

Editor’s note: As this article was being finalized, CMS proposed to return to the hospital inpatient only list all the procedures it removed from the inpatient only list beginning in 2021. This is tentatively scheduled to take effect Jan. 1, 2022. For more information, click here. The impact of this decision, if finalized, will be covered in an upcoming issue of Orthopedics Today.

Click here to read the Point/Counter to this Cover Story.