NYT: Surgeons divided on outpatient total knees for Medicare patients, but support to CMS grows

The New York Times ran an article debating whether Medicare should allow beneficiaries to undergo total knee replacement in outpatient centers with surgeons representing both sides of the issue.

At the center of the story, Ira Kirschenbaum, MD, chairman of orthopedics at Bronx-Lebanon Hospital Center in New York and co-founder of SwiftPath, a technology designed to support outpatient joint replacement centers, describes his satisfaction with the outpatient knee replacement he underwent. At 59 years old, he isn't eligible for Medicare, but he mused that once "crazy" idea of sending patients home after total knee replacements is now a common consideration in his surgical practice.

Surgeons and healthcare professionals are divided about whether outpatient total knee replacement surgery is safe for Medicare beneficiaries; some surgeons have had success with outpatient procedures while others worry the widespread implementation could lead to complications and patient safety issues.

Both sides concede that not every patient — particularly in the Medicare population — is a good candidate for the outpatient setting. In general, outpatient surgery centers serve otherwise-healthy patients undergoing elective procedures. Advancement in surgical technique and pain management partnered with a better understanding of post-surgical rehabilitation and patient education have made outpatient knee replacement possible for a certain subset of patients.

Earlier this year, Medicare floated the idea of removing total knee replacements from the inpatient only list; the agency did so once before in 2012 but abandoned its efforts after receiving negative feedback, according to the report. However, there is more support for outpatient total knee replacements today, according to recent CMS comments. MedPAC recommended CMS remove the procedure from the inpatient-only list in August.

Typically, the physician and patient make the decision together about the appropriate site of service for surgery, but Medicare currently does not reimburse for total joint replacements in ASCs. CMS will likely decide whether to remove total joint replacements from the inpatient only list in 2017. The Times article notes this decision could be reflective of a "changing of the guard" on Capitol Hill, as President-elect Donald Trump takes office with a philosophy to limit government controls.

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