14 key points on total joint replacements in ASCs for 2018

The number of ASCs providing total joint replacements continues to increase, and some administrators are seeing insurance companies become more willing to reimburse for the procedure. However, outpatient total joint replacements remain a relatively novel concept in many parts of the country.

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Here are 14 things to know:

1. The number of ASCs offering outpatient total joint replacements has jumped from around 25 in 2014 to more than 200 in 2017, according to a report from Advisory Board. You can find many of those ASCs listed here.

2. From 2012 to 2015, there was a 47 percent increase in elective outpatient hip and knee replacements, according to Sg2. This trend was an early indicator that total joint replacements are becoming more prevalent in the ASC setting as more surgeons become trained on minimally invasive technology and pain management techniques for outpatient procedures. Additional trends driving total joints outpatient include:

• The shift to value-based care as ASCs are the high quality, low cost setting
• Insurance companies are now more willing to cover outpatient total joints
• Studies show appropriately selected patients can achieve good results in the outpatient setting

3. Last year 15 percent of total joint replacements were performed outpatient; in 2018, Sg2 expects 25 percent of total joints to be performed in an outpatient setting. Here are the projections over the next eight years:

• 2020: 32 percent outpatient
• 2022: 37 percent outpatient
• 2024: 43 percent outpatient
• 2026: 51 percent outpatient

While the report, hosted by Vizient, estimates outpatient total joint replacements will grow 77 percent from 2016 to 2026, inpatient total joint volume is expected to remain relatively flat.

4. CMS removed total joint replacements from the inpatient-only list in 2018, and while some physicians and administrators are excited about the move, others are skeptical, according to an executive roundtable hosted by Medline at the Becker's ASC Review 24th Annual Meeting in October 2017. Payers typically set reimbursement as a percentage of Medicare, which could push commercial payer rates lower than they previously were, depending on where CMS sets the fee schedule. Medicare could also lump implants into one global fee for total joint replacements, which could limit an ASC's ability to negotiate implant carve-outs with commercial payers.

5. Insurance companies have tightened their restrictions around approving total joint replacement cases. Surgeons are likely to receive denials for patients who would have been good surgical candidates in the past based on medical necessity guidelines, and while surgeons can appeal the decision, appeals are sent to peer reviews with non-orthopedic specialists. A Michigan-based ASC reported canceling cases because of last-minute denials from the insurance company.

6. A Georgia-based ASC's administrator reported at the roundtable a bundled payment deal with Blue Cross Blue Shield that has brought in significant case volume. The center performed around 300 total joints already in 2017 and compiled data on quality and cost savings compared to the local hospital. The center's administrator sees the payer engaging in additional efforts to drive appropriate patients to the ASC in the coming years.

7. Nearly half — 48 percent — of Medicare's total knee replacement cases in 2016 that occurred without major complications were performed on patients younger than 80 years old in 2016, according to Advisory Board's Eric Fontana. The patients didn't have a history of falls, obesity or other types of complications such as kidney or heart failure, which could make a portion of them good candidates for ASCs.

8. Around half of total joint replacement patients currently report a one- to two-day length of stay, making them potential candidates for the ASC, according to the Sg2 report. The report also projects 52 percent of primary knee replacements — total and partial — due to arthritis will be performed in the outpatient setting by 2026.

9. Surgeons will likely take outpatient total joint replacements to hospital outpatient departments initially because reimbursement is higher and they have proximity to the hospital. However, as the demand for high-quality, low-cost care increases and surgeons become involved in independent surgery centers, they will take higher volume to ASCs. Site-neutral payment initiatives could also push this trend in the future, according to Sg2.

10. Over the past year, several ASCs took the leap to perform their first outpatient total joint replacements. Here are a few noteworthy examples:

• Robert Hill, DO, performed the first total joint replacement at Vero Beach, Fla.-based The Advanced Center for Surgery in June 2017
• Surgeons at Boston Out-Patient Surgical Suites in Waltham, Mass., performed Massachusetts' first total joint replacement in an ASC in June 2017
• Andrew Wickline, MD, performed Apex Surgical Center's first total joint replacement in December 2017

11. Along with bringing total joint replacements to the ASC, some centers have embarked on bundled payments and price transparency initiatives. For example, Steven Lucey, MD, launched a total joint bundled program in North Carolina and performed the first procedure through the program at Surgical Center of Greensboro (N.C.).

Other centers, including Orthopedic Surgery Center of Orange County in Newport Beach, Calif., post cash rates online. Open partial knee replacement and minimally invasive hip replacement at the center both cost $20,250 and include an overnight stay.

12. ASCs with an outpatient total joint replacement program often have the ability to keep patients overnight. Not all states allow surgery centers the option for overnight stays. ASCs are exploring other options as well, including discharging patients to hotels near the center for close monitoring or working with home health nurses to visit the patients after they're discharged home.

13. A study published in Osteoarthritis Cartilage projects total knee replacements will increase 69 percent from 2012 to 2050, up from 429 procedures per 100,000 people to 725 procedures per 100,000 people. The 143 percent projected increase in total knee replacement volume can be attributed to the increased aging population, desire of Americans to stay active longer and increased obesity rate which places stress on joints, among other factors.

14. SurgCenter Development has launched one of the biggest efforts to support outpatient total joint replacements across the country. The company opened its 100th outpatient center in March 2017 and reported 12 additional centers in development. In 2016, SurgCenter Development physicians performed around 7,000 joint replacements.

More articles on surgery centers:
15+ spine surgeons performing total disc replacement in ASCs
How Anthem's new anesthesia policy for cataract surgery will affect ASCs—5 insights
7 statistics on orthopedics net revenue per case at ASCs


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