16 things to know about outpatient total joint replacements and ASCs

Here are 16 things to know about outpatient total joint replacements and ambulatory surgery centers.


Learn more about outpatient total joints in ASCs and bundled payments from the experts at the Becker's 15th Annual Spine, Orthopedic and Pain Management-Driven ASC Conference + The Future of Spine event, June 22-24, 2017 in Chicago. To learn more and register for the event, click here.

1. Outpatient total joint replacements are on the rise; according to Sg2, from 2012 to 2015, there was a 47 percent increase in elective outpatient hip and knee replacement procedures as reported by Vizientinc. Sg2 predicts there will be 77 percent growth in joint replacements over the next 10 years, but inpatient total joint replacements are only projected to grow 3 percent over the same time period.

2. Outpatient total joint replacement is expected to increase 457 percent for knee replacements and 633 percent for hip replacements nationally in the next decade, according to Sg2.

3. The projected outpatient volume for joint replacement, including partial and total joint replacements, for the next decade are as follows:

• 2016: 15 percent
• 2018: 25 percent
• 2020: 32 percent
• 2022: 37 percent
• 2024: 43 percent
• 2026: 51 percent

4. Nearly half of the total joint population to date spends one to two days in the hospital, according to Sg2; these patients are "ripe for the shift to the outpatient setting." Hospitals are concerned they will see decreased revenues due to outpatient procedures or cases moving into ASCs.

5. An Advisory Board Company analysis found 23 percent of hospitals, out of 354 hospitals surveyed, perform some outpatient total joints; 7 percent perform at least some outpatient hip replacements. The surgeons performing those outpatient procedures said "very few of their patients need skilled nursing, rehabilitation or home care" after their procedures.

6. In 2014, Medicare paid $50,000 on average per hospitalization for total hip and knee replacements, according to Advisory Board, totaling around $7 billion. However, outpatient total joints cost "roughly half as much" as inpatient procedures, which could be a driving force to the outpatient setting for appropriate patients in the future.

7. Total knee and hip replacements were among the first procedures to transition to bundled payments because they are elective procedures with reproducible outcomes. Physicians and providers are able to control much of the care delivered and there is room for cost savings in these procedures. CMS implemented Comprehensive Care for Joint Replacement bundled payments for hospitals in select geographies, and in some regions ASCs are considering bundles.

"Determine how merging your ambulatory and bundled payment strategies can create an attractive fixed fee-offering for commercial payers and local employers to influence referral channels," advised the Sg2 report.

8. President Donald Trump signed an executive order to begin dismantling the ACA on his first day in office, and it could have an impact on CMS bundled payments. CMS expanded their hip and knee replacement bundles for 2017, but after the executive order, the Congressional Research Services sent a memo to postpone any new regulations published on the Federal Register, but not implemented, for 60 days.

Additionally, the new HHS Secretary Tom Price, MD, has been a critic of the Center for Medicare and Medicaid Innovation, which produced CJR. However, the bundled payment program enjoyed bipartisan support in Congress in the past.

9. CMS currently doesn't reimburse for total joint replacement in ASCs, but the Advisory Panel on Hospital Outpatient Payment unanimously recommended CMS remove total knee replacement from the inpatient only list in 2016. CMS also requested additional information on how feasible it would be to remove the procedure in the 2017 payment rule, indicating the agency could take steps toward reimbursement for outpatient total joints in the future.

10. ASC companies are working with their centers to add outpatient total joints. SurgCenter Development reported nearly 7,000 total joint replacements were performed in their 107 ASCs across the United States in 2016, and estimate that number will grow this year. Ninety-six percent of those procedures were same-day discharges. Surgical Care Affiliates, Regent Surgical Health, Meridian Surgical Partners and United Surgical Partners International/Tenet also have ASCs performing total joints.

11. In May 2016, SCA partnered with SwiftPath, a platform that develops evidence-based, rapid recovery protocols for outpatient total joint replacements as well as provides patient education, selection criteria and peer-reviewed surgical techniques. In its third quarter financial report for 2016, SCA reported total joint replacements performed at its facilities more than doubled year-over-year, and the company had 37 facilities performing outpatient total joints.

12. Pacific Rim Outpatient Surgery Center in Bellingham, Wash., celebrated 10 years of total joint replacements last year. The ASC launched its total joint replacement program in 2005 with just one payer; in 2014, the ASC began working with Blue Cross Blue Shield to cover total joints. Avanza Healthcare Strategies President and CEO Joan Dentler sees more payers willing to contract for total joints in outpatient ASCs in the future.

"For ASCs to remain successful in this challenging healthcare environment, it is critical that they develop strong relationships with payers," says President and CEO of Avanza Healthcare Strategies Joan Dentler. "As payers look to further reduce their costs, surgery centers are becoming an even more attractive facility to provide care to members. To not only remain in the payer's network but also receive appropriate reimbursement and coverage for 'new' procedures, such as spine and total joints, ASCs must closely track their financial outcomes data and be prepared to present this information during contract negotiations as supporting evidence for a fair and comprehensive contract."

13. Device companies are increasingly developing strategies around value-based care and outpatient orthopedic procedures. Smith & Nephew's Syncera, DePuy Synthes Advantage, Zimmer Biomet's Signature Solutions and FlowerOrthopedics' FlowerAdvantage are a few examples. These programs aim to help lower the cost of care while maintaining or improving quality.

14. Research on same-day total joint replacement patients found comparable outcomes to inpatient orthopedic surgeries. The research, presented at the American Academy of Orthopaedic Surgeons annual meeting in 2014, examined 243 patients who either underwent inpatient or outpatient total knee or hip replacement surgery. The researchers found:

• 10.2 percent of the patients who underwent outpatient procedures were readmitted within 30 days of surgery, compared to 6.6 percent of the inpatient procedure group.
• The hospital length of stay didn't have an impact on patient satisfaction measurements.
• Outcomes were comparable between the two groups.

15. Pain management and anesthesia advancement has played a big role in transitioning total joints to the outpatient setting. According to an article by Jack M. Bert, MD, of Minnesota Bone & Joint Specialists, adductor canal blocks are the anesthesia procedure of choice for total knee arthroplasty. Short acting spinal blocks allow for rapid rehabilitation and a decreased risk of postoperative nausea and vomiting. The anesthesia techniques can help patients ambulate sooner after surgery and return home the same day. The patient's postoperative recovery can include oral hyrdrocodone and intravenous fentanyl "for breakthrough discomfort."

16. Patient selection is critical, as not all patients are good candidates for outpatient total joint replacement. Dr. Bert recommends patients be ASA class 1 to 3 and have a BMI of 35 or less, although he acknowledged that some surgeons will take patients with a BMI up to 40 if the patient is otherwise healthy. Some surgeons also require patients to be 70 years old or younger.

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