Total shoulder replacement in ASCs: 5 key concepts from Dr. Vishal Mehta

Total knee and hip replacement procedures are transitioning into the outpatient surgery center setting, and now Fox Valley Orthopedic Institute surgeon Vishal Mehta, MD, is performing total shoulder replacements in an ASC as well.

But that transition doesn’t happen overnight. It takes time to educate patients and accumulate the right equipment so these procedures can be done safely. Here are five key concepts:

1. Patient selection is key for success at ASCs. Dr. Mehta developed protocols for patient selection and began performing outpatient total shoulder replacements while taking patients to Northwestern Medicine’s Delnor Hospital; now, he performs about half of his routine total shoulder replacements as outpatients and a growing number at the ASC.

“It’s great for patient care because there aren’t as many superbugs or MRSA at surgery centers. Hospitals are a great place to be if you truly need them but if a procedure can be performed safely in an ASC it is usually better for all involved…and most importantly the patient,” says Dr. Mehta. “We are able to perform the surgery efficiently at the ASC. It’s also financially responsible. We take a $30,000-40,000 procedure and cut that cost in half. Hospitals”

2. Payers are a factor in making the outpatient transition. “We got buy-in from Blue Cross Blue Shield. Now they understand the value of total joints in the ASC when that’s what is best for patients,” says Dr. Mehta. “We spoke with them and they’re excited for their members to have access to the ASC.”

The data Dr. Mehta and his team brought to the negotiating table includes:

• Readmission rates
• Quality data
• Cost statistics

“It’s easy for them to give you a capped rate less than what they’re paying the hospital,” says Dr. Mehta. “But you have to convince them you’ll provide a quality outcome and the procedure isn’t dangerous.”

The ASC doesn’t have total shoulder replacement coverage from all area payers yet, but a few big payers are on board. Dr. Mehta and his team were able to build a good relationship with payer representatives, and he even previously helped write guidelines on meniscal transplants for BCBS.

3. The patients are typically excited about outpatient surgery. They know hospitals have high infection rates and would rather undergo surgery at the ASC if possible. But it's important to discuss anesthesia and pain management with the patients so they know what to expect when they return home.

“Patients have a lot of apprehension, so it’s the surgeon’s job to make sure they know they’ll be okay when they return home,” says Dr. Mehta. “Let them know what the progression will be like; that takes away the apprehension.”

4. New equipment purchase will be necessary. Even orthopedic-focused ASCs will likely need to make additional capital purchases to acquire the right equipment and sterilizers so the team can process total joint replacement trays.

“It takes a heavier duty saw for me to make the right cuts, so we had to purchase that. There were a few other modifications we had to make and then train our staff,” says Dr. Mehta. “We had the trays brought in ahead of time to show the staff what the instruments and retractors looked like. My staff also watched a video on shoulder replacements so they could see what was involved. We did a trial run before the first case.”

5. Implants can make the procedure cost-prohibitive if vendor contracts aren't properly negotiated. High acuity orthopedic cases can be cost-prohibitive if the implant vendors aren’t willing to negotiate on prices. “Typically it’s in the best interest of the implant vendors to work with you,” says Dr. Mehta. “They see orthopedic surgery moving from the inpatient to the outpatient setting and they have to find a way to provide implants at a cost that works in the ASC.”

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