Time to accept role of outpatient total joint, spine procedures at all levels

Issue: August 2016

ByAnthony A. Romeo, MD

There has been a dramatic increase in the number of joint arthroplasty procedures performed as outpatient procedures. This increase has been seen despite CMS’ restriction of “hospital only” for joint arthroplasty CPT codes.

For more than a decade, to allow joint arthroplasty procedures to be appropriately reimbursed in an outpatient setting, surgeons and hospitals have been performing the procedures in the hospital-based OR, admitting patients to the hospital after the recovery room process and then later in the same day discharging patients home. Although the patients are officially admitted to the hospital to fulfill an archaic restriction in payment for the procedure, this defines the practice of outpatient joint replacement.

The same process has been used with other procedures, such as cervical and lumbar spine fusions. Across the United States, local relationships between physicians and payers have led to contracts to allow surgeons to perform joint arthroplasty and spine procedures in an outpatient setting despite CMS’ restrictions.

Anthony A. Romeo

Outpatient experience

Individual physicians and the ambulatory surgery industry have been leaders in the process of outpatient joint arthroplasty. However, it is not uncommon to hear accusations that surgeons are making changes to increase revenue as they may have equity or ownership in ambulatory surgery centers (ASCs), or joint ventures or gainsharing relationships with their hospitals.

However, conflicts of interest can be found on both sides of the discussion. Hospital or medical center employees suggest outcomes for outpatient cases are not the same as inpatient cases within their system. Institutional-based physicians may be correct in their assessment that outpatient joint arthroplasty and spine procedures are not as effective in their system. While they may anecdotally report challenges to affect change, the primary reason for less success is outpatient procedures require a different approach to patient management than either the physician or system that they work in has established for the procedures.

Outpatient surgery requires a coordinated approach that begins preoperatively. The clinical pathway begins with the decision to proceed to joint arthroplasty or spine surgery and continues for 90 days after the procedure. Patients require a higher level of education preoperatively so there can be adequate preparation before surgery and once they return home. Assessment of home support is critical to ensure a successful outpatient discharge. Patients need to be provided with postoperative medications and clear instructions on preoperative surgical site preparation and postoperative wound care. Once at the outpatient center, staff need to be on the same page as the surgical team to provide a relaxed and consistent care plan.

Advances in surgical technique also play a critical role. Minimizing damage to the normal surrounding tissue and protecting structures damaged by older, more invasive approaches should be part of the surgical plan. Accomplishing the appropriate critical steps of the procedure, including implant placement or fusion, is also a requirement and readily accomplished with modern techniques. Wound closure and effective wound dressings are also valuable. Finally, patients need to be able to ambulate, which can be instructed preoperatively and then revisited and refined postoperatively, often with the supervision of a physical therapist.

Anesthesia care

A major component of successful outpatient surgery is the care provided by the anesthesiology team. When the anesthesia and surgical teams work together, the patient experience is greatly enhanced. Consistent protocols for anesthesia care, which takes into account preoperative measures to reduce pain and anxiety, intraoperative techniques to minimize the need for narcotic medication, preemptive medications for nausea, and postoperative care that rapidly recovers patients from the surgical procedure have been developed to the point that consideration for using these modern techniques should be standard for all patients who have minimal comorbidities, even if the procedure is performed in an inpatient setting.

Another key feature for the anesthesia care is the development of expertise in regional anesthesia. Just as it is impossible for every surgeon to be able to develop expertise with hip arthroplasty, regional anesthesia care requires an added level of training to attain expertise that can be translated into improved outcomes, reduced complications and outstanding patient experience. Without a sophisticated team approach between the surgeon and anesthesiologist, outdated methods of anesthesia care could remain common in many settings, making it impossible to provide the best patient experience and opportunity for outpatient procedures.

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Economics

The economics of outpatient joint arthroplasty are remarkable. In the United States, the National Center for Health Statistics, part of the CDC, reported 719,000 total knee arthroplasties and 332,000 total hip arthroplasties were performed as inpatient procedures in 2010. More than half of these patients were older than 65 years and 44% were between 45 years to 64 years.

It is likely more than 50% of these cases could have been performed as an outpatient procedure in an ASC based on modern clinical protocols, state-of-the-art anesthesia and surgical techniques. However, CMS has not approved the procedures for outpatient care. Instead, the government approach to the management of costs for joint replacement is a bundled payment program as defined by the Comprehensive Care for Joint Replacement model. With this approach, ideally a single payment is established for an entire episode of care that includes the cost of all providers, implants and equipment.

The process was initially established to be a hospital-based program, which failed to demonstrate the effectiveness and cooperation the government envisioned. If the hospital did not employ the physicians, it typically was challenging to find a compromise in the method for the distribution of funds from the single payment to all providers. This is not surprising considering the lack of transparency in the cost of care not only throughout the entire medical community, but especially in hospital and health care institutions.

Cost structure

Inflated price structuring has been documented in the media with variations in costs greater than a factor of 10. There is additional evidence hospitals in a “monopoly market” with three or fewer major providers of care are typically 15% higher in terms of cost. It is also remarkable that the same procedure performed in an ASC owned by a hospital will be reimbursed 81% higher than if performed in a non-hospital-owned ASC. The difference in price between the same procedure performed in the hospital’s inpatient OR vs. a hospital outpatient department may be greater than an additional 20%.

If the cost structure used to determine the bundled payment distribution among providers is based on historically high hospital costs, the contract will be unappealing to surgeons who are aware of the true costs of providing care. This is not only a problem for the fixed reimbursement offered by Medicare for an episode of care, but it also affects negotiations with private payers as they move toward bundled payment models.

Price transparency is critical for an educated, informed debate on the overall costs of traditionally hospital-based procedures such as joint replacement and spine surgery. Remarkably, CMS approved in 2015 the following procedures for ambulatory surgery centers: neck spine fusion; lumbar spine fusion; spine fusion extra segment; neck spine disc surgery; laminectomy single lumbar; removal of spinal lamina; and decompression of spinal cord. CMS and other payers need to reassess their policies regarding joint arthroplasty and also approve the procedures for ASCs.

The debate is not about the increase revenue to the owners of ASCs — it is a value proposition to patients and payers. If the value of a procedure is determined by the benefit divided by the cost, and the cost is reduced 40% or more for the same procedure performed in an inpatient hospital setting, then it would take a tremendous reduction in benefit to suggest that our patients, a population of more than 1 million people per year, are not receiving the same value.

Fortunately, recent reports and ongoing studies confirm that outpatient joint arthroplasty in properly selected patients has the same or improved benefit. Outpatient joint arthroplasty is rapidly increasing for knee, hip and shoulder arthroplasty through selected programs and payer relationships and is likely to surpass 50% of all cases of joint replacement and spine surgery one day. It is time to formally accept the role of outpatient joint and spine procedures at all levels so patients can experience state-of-the-art care for the best value.

For more information:
Anthony A. Romeo, MD, is the Chief Medical Editor of Orthopedics Today. He can be reached at Orthopedics Today, 6900 Grove Rd., Thorofare, NJ 08086; email: orthopedics@healio.com.

Disclosure: Romeo reports he receives royalties, is on the speaker’s bureau and a consultant for Arthrex; does contracted research for Arthrex and DJO Surgical; receives institutional grants from AANA and MLB; and receives institutional research support from Arthrex, Ossur, Smith & Nephew, ConMed Linvatec, Athletico and Miomed.