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Removal of TKA from inpatient-only list may impact patient care
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When the 2018 Medicare Outpatient Prospective Payment System Rule was finalized in November 2017, removing total knee arthroplasty procedures from the Medicare inpatient-only list, CMS indicated a small percentage of Medicare patients would be expected to receive a knee replacement as outpatients, according to a press release from the American Association of Hip and Knee Surgeons. However, a survey conducted by AAHKS showed the new Medicare rule is not being interpreted by hospitals as intended by CMS.
“The problem is that certain hospitals are telling their surgeons that all of their knee replacement patients need to be performed as outpatient procedures, and we do not think that that is safe,” Advocacy Council Chair of the AAHKS and co-author of the study, James I. Huddleston III, MD, told Healio.com/Orthopedics.
Survey results
Active members of AAHKS were asked to complete a nine-question survey that assessed whether the surgeon’s hospital was treating all patients undergoing TKA as outpatients, if Medicare Advantage administrators and commercial payers were treating all or most patients the same and what the impact was on surgeon practices and their patients.
Of the 730 members who responded, results showed 59.9% of surgeons were instructed by their hospitals to schedule all Medicare TKAs as outpatient procedures. Huddleston and colleagues found if the patient was admitted but did not stay a second midnight, 49.8% of surgeons reported the patient would be treated as an outpatient, while 43.4% of surgeons reported hospitals would seek a change to inpatient status for patients who stayed fewer than two midnights. Overall, 40.5% of surgeons were asked to use proscribed documentation to justify the change.
The survey also showed these changes may affect patients, with 30.4% of surgeons reporting incurred added personal cost to the patient related to their TKA being billed to CMS as an outpatient procedure. The issue was also reported as an administrative burden by 76.1% of surgeons.
Identify the right patients
Although AAHKS is supportive of TKA performed as an outpatient basis, Huddleston said more data are needed on which patients can undergo outpatient TKA safely.
“Historically, knee replacement has been an inpatient procedure and that was because our patients have medical problems and they had fair amounts of pain and we needed to keep them in the hospital to help get them through the perioperative process,” Huddleston, who is associate professor of orthopedic surgery at Stanford University Medical Center and chief of the adult reconstruction service, said. “As our techniques have improved, pain control is better, and we think that safety is better to the point where certain patients should be able to go home assuming they have the resources to support themselves there but as of now, we do not know who those patients are.” – by Casey Tingle
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Disclosures: This study was funded by the American Association of Hip and Knee Surgeons. Huddleston reports that he serves as the advocacy council chair for AAHKS.
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