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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?
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Shift to ASC lends flexibility
The right care in the right place at the right time has long been a mantra at Geisinger. Migrating orthopedic procedures to an outpatient setting remains in line with that concept.
Every year, millions of Americans undergo various procedures, spending days in the hospital when it is becoming increasingly plausible to do many procedures in outpatient settings. Advancements in surgical techniques, pain management and the capabilities of outpatient environments have paved the way for a shift to outpatient settings. Physician training, patient education and home health models have also supported this transition.
Ultimately, this kind of shift would increase flexibility for physicians to perform procedures in the setting they determine most clinically appropriate. As a result, patients would benefit further by having additional, safe options available to them. Notably, outpatient settings frequently present a more favorable patient experience due to their operational efficiency and they are attractive as a setting not subject to the same risk of hospital-acquired conditions.
Given these dynamics, allowing for the safe performance of certain procedures in an outpatient setting strikes the right chord for quality, patient experience and value. As such, our bias is toward greater physician and patient flexibility.
Jaewon Ryu, MD, JD, is executive vice president and chief medical officer, Geisinger, in Danville, Pa.
Disclosure: Ryu reports no relevant financial disclosures.
A move toward shorter hospital length of stay
Whether to perform the same TKA in a hospital outpatient department or ASC is dependent upon appropriate patient selection and proficiency of the surgical outpatient program, including surgeon experience, patient optimization, preoperative patient education, regional anesthesia, multimodal analgesia and postoperative home monitoring with good family support. In transitioning to same-day TKA, it is important surgeons feel comfortable with a shorter hospital stay and have been involved in a rapid recovery program within the hospital setting. A healthy Medicare patient who is optimized for surgery accepts and understands the implications of going home, and has a support system at home, may be well suited for same-day surgery at either facility. However, patients with multiple complex comorbidities, such as heart disease, diabetes, obesity and hematologic disorders, or who lack of a good home support system may be better suited for surgery in the hospital, where a stay of 1 day to 2 days may be needed to monitor and stabilize the patient in preparation for discharge home. Although some physicians at ASCs have performed outpatient TKAs, hospitals have gained experience with value-based programs, such as the Bundled Payment for Care Improvement and Comprehensive Care for Joint Replacement (CJR), with the Medicare TJA patients and should be well suited for safely performing same day TKA in select patients. Therefore, as we move toward a shorter hospital length of stay for healthy and motivated Medicare patients, we will ultimately experience more TKAs being done as hospital ambulatory procedures and eventually a further migration towards ASCs.
Giles R. Scuderi, MD, is an orthopedic surgeon at Lenox Hill Hospital and Vice President of the Orthopedic Service Line at Northwell Health, New York City.
Disclosure: Scuderi reports he is a consultant for Pacira and Medtronic; receives publication royalties from Springer, Elsevier, Thieme and World Scientific; and receives royalties and is paid by Zimmer Biomet for development and consulting.
Proceed with caution
Medical policies and reimbursement strategies for TKA should be designed to optimize health outcomes at the lowest possible episode cost. CMS’ proposal to remove TKA from its ‘inpatient-only’ list warrants careful consideration of possible impacts on patient outcomes and cost.
Most clinicians would agree that for patients with significant medical comorbidities and/or limited home support, ie, most Medicare beneficiaries, ambulatory TKA is not safe. It has been suggested that patients with a low risk of complications could be safely treated in an ambulatory setting. But, can we reliably identify these patients? Probably not. In one series of more than 1,600 patients treated at a single high-volume center, the rate of serious complications within 6 weeks was 11% with most occurring within 4 days of surgery. More remarkable was 58% of patients who had serious complications had no identifiable predisposing factors. Hence, it is likely that even if ‘low-risk’ Medicare beneficiaries are treated in an ambulatory setting, some will have serious complications. How will those patients fare? During the past decade, mortality rates for TKA declined, but complication rates did not change. This suggests we have gotten better at identifying and managing complications within hospitals using sophisticated monitoring. Our ability to identify and “rescue” patients from such serious complications in the home setting is unknown. It is possible we could develop and deploy home monitoring programs that would keep patients safe, but we currently have little experience in this realm.
At the very least, ambulatory TKA will require some level of home health services coordinated with the treating facility to ensure safety. We should anticipate some percentage of those patients will require readmission. Whether shifting some TKAs to the ambulatory setting will result in lower costs or greater complication rates at the population level is unknown. Rather than implementing a nationwide policy to remove TKA from the inpatient-only list, I suggest taking a measured approach that would allow assessment of the health and financial impacts of ambulatory TKA in a safe environment. Specifically, I propose removing TKA from the ‘inpatient-only’ list only for facilities participating in the CJR program. Health outcomes and cost of care for populations managed at these facilities are being closely monitored. Additionally, since these facilities have already put into place care structures and processes to monitor patients post-discharge, patients who do develop complications after discharge are more likely to be identified in a timely manner. Such a measured approach would minimize potential risks for patients and provide the needed patient outcome and cost data to inform the development of a policy that will promote high-value health care.
- Reference:
- Parvizi J, et al. J Bone Joint Surg Am. 2007;doi:10.2106/JBJS.E.01443
Catherine H. MacLean, MD, PhD, is Chief Value Medical Officer at Hospital for Special Surgery in New York City.
Disclosure: MacLean reports no relevant financial disclosures.