How to set up total joint and spine programs at ASCs — and what to expect from insurers in 3-5 years

Surgeons across the country are beginning to perform outpatient total joint replacements and spine surgery in an ASC. Outpatient procedures are associated with lower infection rates and reduced costs, providing better value to the healthcare system.1

DePuy Synthes hosted a workshop on June 22, 2017 at the 15th Annual Becker's Spine, Orthopedic & Pain Management-Driven ASC Conference + The Future of Spine about starting total joint and spine surgery programs at ASCs. Dan Hoeffel, MD, an orthopedic surgeon at Woodbury, Minn.-based Summit Orthopaedics; Michael Kachmann, MD, a neurosurgeon at Cincinnati-based Mayfield Clinic; and Derek van Amerongen, MS, MD, vice president and medical director of Humana of Ohio, spoke on the panel.

Key factors for ASC programs
In 2008, over 41 percent of the total joint replacements were performed on patients younger than 65 years old; many of those patients could be eligible for outpatient total joints.2 Medicare doesn't currently reimburse for total joint replacements in the ASC setting, but private insurance companies are increasingly interested in contracting for the procedures in a safe, lower cost setting. Surgeons also see opportunity to control the patient's experience at the surgery center with a knowledgeable surgical staff, input on implants and control over postsurgical care.

Dr. Hoeffel works in a high volume total joint ASC and his new perspective is that "the value equation is quality over payment, and we can adjust the payment element here to create better value.

In some states, ASCs are able to keep patients for 23 hours, or construct a convalescence center to transfer patients postoperatively. Depending on state regulations, surgeons can bring joint replacement procedures into their centers and safely monitor their recovery.

According to the panelists, the key steps to starting a total joint replacement or spine program in an ASC include:

• Align surgeons with anesthesia, midlevel providers and the nursing staff
• Agree on patient selection criteria
• Develop a pre-surgical patient education plan
• Identify barriers to patients not progressing in rehabilitation
• Remove any roadblocks to recovering at home
• Employ a multimodal pain management protocol for outpatient surgery
• Design a postoperative mobility protocol and work with nurses to implement
• Create a follow-up plan to connect with patients after they return home

Dr. Hoeffel described Summit Orthopedics' first 400 outpatient total joint replacement patients, finding a 1.25% readmission rate for total knee arthroplasty and 1.79% for total hip arthroplasty. To prevent unnecessary readmissions, the surgeons asked patients to call them or their urgent care centers instead of going to the emergency room unless the patient had chest pain.

Surgery centers can go a step beyond delivering quality patient outcomes to improving the patient and family experience. Dr. Kachmann described how the Mayfield Clinic's outpatient spine surgery program took the next step in keeping patients and their families satisfied by installing snack and drink machines, wireless internet and private patient rooms. The patient has the same preop and postop room to eliminate confusion, and the same nurse follows the patient throughout their episode of care.

"We do a fair amount of Medicare patients, but they still have to be mobile and motivated patients," said Dr. Kachmann. "We set the expectation that they'll be ready to go home after surgery."

Mayfield Clinic receives word-of-mouth referrals from former patients to their family and friends because of the high patient satisfaction rates. "The highly experienced staff doing the same procedure over and over again makes the surgery center attractive not only for the patient but the surgeon as well," said Dr. Kachmann.

Insurance coverage
There is considerable momentum to develop value-based care and align across the care continuum. Millennials will be the next generation to impress; currently, around half of Humana beneficiaries will be millennials by 2020 and will require a different approach to care than older generations.

"Everything we've been taught, everything we teach, everything we like, isn't going to be what our customers are asking for in three to five years," said Derek van Amerongen. "They want everything in real time and on their phones. If you can't provide that experience and immediate results, they don't want to work with you. That is leading to a fundamental re-shifting in healthcare beyond what is involved in regulation or legislation."

From a payer perspective, Derek van Amerongen commented, "We are looking for an opportunity to begin that discussion around innovative contracting over the next three to five years," he said. He touched on linking reimbursement to outcomes in terms of functionality and value.

Bundled payments and episodes of care shift more risk onto the patient and healthcare provider, and linking reimbursement to outcomes will become more prevalent going forward. Traditionally, the opponents to linking reimbursement to outcomes argued there were too many elements of care surgeons couldn't control. That's no longer true.

"With the right environment, facilities and processes, we can have highly reproducible outcomes to pay for value," said Dr. Kachmann. "This is an enormous opportunity for each of us who wants to get involved. Go back and do the work to understand your internal culture, demonstrate improved outcomes and show you deserve more control because you can demonstrate improved, patient-centered outcomes."

He recommended taking data to insurance companies to prove each center provides the best value to their membership. "We are moving in the next three to seven years to a place where payers are going to be very anxious to pare down their narrow networks," said Derek van Amerongen. "Where we are going is to an environment where networks will be much more narrow and much more selective…I want people in my network that are high powered, who are delivering high quality outcomes and willing to take risk and be part of that solution on how we get to ideally providing better healthcare instead of just better medical care."


1. Infection Control Today: "Study Finds Low Rate of Surgical Site Infections Following Ambulatory Surgery." Feb. 18, 2014.

2. Losina, E. et al. Journal of Bone and Joint Surgery: "The dramatic increase in total knee replacement utilization rates in the United States cannot be fully explained by growth in population size and the obesity epidemic." Feb. 1, 2012.

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