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News that CMS removed TKA from inpatient-only list comes at start of AAHKS meeting
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DALLAS — The American Association of Hip and Knee Surgeons Annual Meeting got underway here on Nov. 2, the day after an announcement from CMS that it finalized its Outpatient Prospective Payment System rule, which effectively moved total knee arthroplasty from the CMS inpatient-only, or IPO, list to its outpatient list.
What that means for orthopedic surgeons is that starting in calendar year (CY) 2018, TKA no longer must be performed on Medicare patients solely in the inpatient setting, as is currently the case.
According to the CMS press release about the Outpatient Prospective Payment System (OPPS), “The OPPS final rule also has policies that would make OPPS payment available when Medicare beneficiaries receive certain procedures in a lower cost setting of care – the outpatient department – where those procedures can be safely performed in that setting. The new availability of OPPS payment applies to six procedures, including a common and costly Medicare surgical procedure, total knee replacements. Starting January 2018, Medicare beneficiaries [who] undergo any of these procedures can opt to have them performed in a lower cost setting of care where a clinician believes such a setting is appropriate.”
On Nov. 10, the American Association of Hip and Knee Surgeons (AAHKS) wrote in a statement on this development it “agrees with CMS’s statement that ‘the decision regarding the most appropriate care setting for a given surgical procedure is a complex medical judgment made by the physician based on the beneficiary’s individual clinical needs and preferences.’ It is important to AAHKS that surgeons and patients choose the appropriate setting and time of discharge after surgery without influence by negative incentives or reimbursement consequences. This requires that CMS closely monitor emerging data as this policy is implemented to measure the impact on the BPCI and CJR models.”
A Nov. 3 press release from the American Academy of Orthopaedic Surgeons, said, “AAOS applauds CMS for removing TKA from the IPO list and for acknowledging this decision should be ‘made by the physician based on the beneficiary’s individual clinical needs and preferences.’ AAOS further applauds CMS for noting that ‘the surgeons, clinical staff, and medical specialty societies who perform outpatient TKA and possess specialized clinical knowledge and experience’ are most suited to create guidelines to identify appropriate candidates. AAOS is currently developing measures to assist selection of the ideal candidate for these procedures.” As noted in the AAOS release, “While CMS is not adding TKA to the ASC covered surgical procedures list for CY 2018, AAOS is encouraged by the progress announced in the final rule and will work closely with CMS to ensure this important next step happens as soon as possible.” – by Susan M. Rapp
- References:
- AAHKS Responds to CMS Outpatient Rule and TKA Reimbursement Change. Available at: www.aahks.org/aahks-news/welcome-to-the-aahks-newsroom/aahks-responds-to-cms-outpatient-rule-and-tka-reimbursement-change/. Accessed Nov. 16, 2017.
- AAOS Responds to CMS Outpatient Rule, TKA Announcement. Available at: http://newsroom.aaos.org/media-resources/Press-releases/aaos-responds-to-cms-outpatient-rule-tka-announcement.htm. Accessed Nov. 4, 2017.
- Changed setting for joint reconstruction surgery possible in 2018. Orthopedics Today, 2017; 37(10):10-12.
Perspective
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Kevin J. Bozic, MD, MBA
The CMS decision to remove TKA from the inpatient-only list is indicative of the progress made in the management of TKA patients in the past decade. Advances in surgical technique, multimodal pain management, early mobilization and rapid rehabilitation have allowed a procedure that only 10 years ago required a 3-day to 4-day hospital stay to be done safely and effectively in the outpatient setting. Many pioneering surgical teams have been safely performing TKA procedures in commercially insured patients in the outpatient setting for the past several years. This landmark decision by CMS will now allow Medicare beneficiaries to benefit from these advancements in care. It remains incumbent upon orthopedic surgeons and their perioperative care management colleagues to carefully select Medicare patients who are most likely to benefit from outpatient TKA based on their physiologic age, comorbid conditions and social support status. Although it is somewhat disappointing CMS did not add TKA to the list of ASC-covered procedures, this policy decision is a step in the right direction, and hopefully the experience gained with outpatient TKA in the coming year will allow all stakeholders to feel comfortable with TKA being performed in stand-alone ASCs.
Perspective
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Richard Iorio, MD
I applaud CMS for its decision to slowly implement same-day discharge TKA for Medicare beneficiaries. It is our hope that as institutions collect more safety and outcomes data on same-day discharge programs, CMS allows surgeons and patients to choose the appropriate setting and time of discharge after surgery without consequences for reimbursement and incentives that may affect care. We also believe that, following careful analysis, total hip arthroplasty should follow suit and be removed from inpatient-only considerations. At NYU Langone Health where we launched a same-day discharge joint arthroplasty program in 2015, we have seen firsthand that patients who meet our selection criteria for same-day discharge have great outcomes, and such a CMS ruling may enable us to expand our program to more patients who may benefit in this way.
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